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ICD-10-CM L81.3, Cafe au lait spots | No Prior Auth

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`L81.3`, Cafe au lait spots

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Clinical documentation of signs and/or symptoms consistent with a genetic disorder.
Documentation that prior clinical evaluation and standard laboratory tests and/or imaging were non-diagnostic or inconclusive.
Documentation that test results are expected to inform clinical management or obviate further diagnostic testing.
Providers must reference the most up-to-date sources of professional coding guidance prior to claim submission.

Key Coverage Criteria

Genetic testing for Legius syndrome.
Lymphangioleiomyomatosis (LAM) consistent with clinical diagnostic criteria.
Multiple retinal nodular hamartomas identified on ophthalmologic exam.
Two or more renal angiomyolipomas.
Presence of a Shagreen patch (connective tissue nevus).
Presence of 'confetti' skin lesions (numerous 1–3 mm hypopigmented macules).

1 Active Policy

AMBETTER-CG-Multi-Inher-DO.-Intel-Dis.-DD-2025.1, Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay

Related Codes

0214U(1 policies)0215U(1 policies)81162(1 policies)81185(1 policies)81216(1 policies)81222(1 policies)81223(1 policies)0156U(1 policies)

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Refer to the Concert Platform for the comprehensive list of registered tests.

Medical record documentation of functional severe developmental delay with age of onset (6–12 months) and documentation of at least one clinical feature supporting Angelman syndrome.