Does L89.154 require prior authorization?

Yes, L89.154 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

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`L89.154`, Pressure ulcer of sacral region, stage 4

ICD-10-CM

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation Required

A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for the HCPCS codes specified under Final Rule 1713 and the WOPD must be obtained prior to delivery.
Suppliers must retain evidence in their files that all related LCD coverage criteria have been met and make that evidence available to the DME MAC upon request.
Suppliers must add the KX modifier to E0194 on the initial claim only if all LCD criteria are met and evidence is retained; for each subsequent monthly claim, add KX only if the treating practitioner's monthly certification documents continued medical necessity and discontinue KX if criteria are not met.
The treating practitioner must document monthly in a written statement the need for the equipment, specifying the size of the ulcer, if the ulcer is not healing what other aspects of the care plan are being modified to promote healing, and that continued use is reasonable and necessary for wound management; the supplier must keep this on file and available for inspection.

Key Coverage Criteria

Pressure-reducing support surfaces (Group 3) including air-fluidized beds (HCPCS E0194) are covered under the Durable Medical Equipment benefit when reasonable and necessary and when the related LCD coverage criteria are met.
Heavy-duty and bariatric devices are included in Group 3 and coded as E0194 when they meet coverage criteria.
Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit when the item is eligible under Medicare, meets the reasonable and necessary (R&N) criteria in the related Local Coverage Determination (LCD), and satisfies applicable Medicare statutory and regulatory requirements.
HCPCS E0277 (powered pressure-reducing mattress) is payable when the product has an air pump/blower providing sequential inflation/deflation or low interface pressure, inflated cell height >= 5 inches, design that provides beneficiary lift/reduces pressure/prevents bottoming out, a surface to reduce friction and shear, can be placed on a hospital bed frame, and R&N LCD criteria are met.
HCPCS E0193 (semi-electric or total electric hospital bed with fully integrated powered pressure-reducing mattress) is payable when the integrated mattress meets the E0277 characteristics and R&N LCD criteria are met.
HCPCS E0371 (advanced nonpowered pressure-reducing mattress overlay) is payable when individual cell height/design provide significantly more pressure reduction than group 1 overlays and prevent bottoming out, total height >= 3 inches, surface reduces friction/shear, documented evidence of effectiveness exists, the product is listed on the PDAC Product Classification List (PCL) with a written Coding Verification Review (CVR), and R&N LCD criteria are met.

19 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

WPS-J5-L37228, Wound Care

A55909, Billing and Coding: Wound Care

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

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L89.154, Pressure ulcer of sacral region, stage 4