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ICD-10-CM L57.3, Poikiloderma of Civatte | No Prior Auth

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`L57.3`, Poikiloderma of Civatte

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of infection when applicable (e.g., diagnosis of warts, molluscum contagiosum).
Documentation that the lesion restricts vision or obstructs a body orifice, if that is the basis for removal.
Clinical description consistent with suspicion for malignancy using ABCDE features (asymmetry, border, color, diameter >6 mm, evolving) where removal is for concern of malignancy.
Biopsy/pathology report when biopsy has been performed showing premalignancy or malignancy (this is an explicit selection criterion).

Key Coverage Criteria

Removal of acquired nevi (moles) when any of the selection criteria below are met.
Removal of small congenital nevi (less than 1.5 cm) when any of the selection criteria below are met.
Removal of cutaneous and subcutaneous neurofibromas when any of the selection criteria below are met.
Removal of dermatofibromas when any of the selection criteria below are met.
Removal of dermatosis papulosa nigra when any of the selection criteria below are met.
Removal of acrochordon (skin tags) when any of the selection criteria below are met.

2 Active Policies

ANTHEM-CG-LAB-21, Serum Iron Testing

AETNA-CPB-0633, Benign Skin Lesion Removal

Related Codes

D36.9(2 policies)11300(1 policies)17004(1 policies)11400(1 policies)11446(1 policies)17000(1 policies)11313(1 policies)11201(1 policies)

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Clinical documentation explaining which medical necessity criterion is met (e.g., notes documenting recurrent trauma/irritation due to lesion location).

Clinical notes documenting symptoms attributable to the lesion (e.g., bleeding, burning, intense itching, irritation).