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ICD-10-CM L41.0, Pityriasis lichenoides et varioliformis acuta | No Prior Auth

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`L41.0`, Pityriasis lichenoides et varioliformis acuta

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

An in-home Ultraviolet B (UVB) light therapy delivery device is consideredmedically necessarywhen conditions A and B are met:
The treatment is foroneof the following conditions:Atopic dermatitis, when topical treatment alone has failed;orCutaneous T-cell lymphoma, including mycosis fungoides and SÃ©zary syndrome;orPityriasis lichenoides;orPruritus of hepatic disease;orPruritus of renal failure;orPsoriasis, when topical treatment alone has failed;orVitiligo, when topical treatment alone has failed;and
Atopic dermatitis, when topical treatment alone has failed;or
Cutaneous T-cell lymphoma, including mycosis fungoides and SÃ©zary syndrome;or
Pityriasis lichenoides;or
Pruritus of hepatic disease;or

1 Active Policy

ANTHEM-CG-DME-41, Ultraviolet Light Therapy Delivery Devices for Home Use

Related Codes

C84.0A(1 policies)C84.10(1 policies)C84.1A(1 policies)C86.6(1 policies)C86.60(1 policies)C86.61(1 policies)E0691(1 policies)C84.00(1 policies)

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