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ICD-10-CM L73.0, Acne keloid | No Prior Auth

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`L73.0`, Acne keloid

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

Treatment of a keloid is consideredmedicallynecessarywhen both of the following are present:
There is documented evidence of significant functional impairment related to the keloid;and
The treatment can be reasonably expected to improve the functional impairment.
Treatment of a keloid with radiation therapy (up to 3 fractions) is consideredmedically necessaryas adjunct therapy following surgical excision (initiated within 3 days) when the medically necessary criteria for keloid removal are met.
Treatment of a keloid isreconstructivewhen the keloid results in a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease.
Treatment of a keloid with radiation therapy (up to 3 fractions) is consideredmedically necessaryas adjunct therapy following surgical excision (initiated within 3 days) when the reconstructive criteria for keloid removal are met.

1 Active Policy

ANTHEM-CG-SURG-31, Treatment of Keloids and Scar Revision

Related Codes

11401(1 policies)11402(1 policies)11403(1 policies)11404(1 policies)11406(1 policies)11420(1 policies)11421(1 policies)11400(1 policies)

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