Does L89.42 require prior authorization?

No, L89.42 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`L89.42`, Pressure ulcer of contiguous site of back, buttock and hip, stage 2

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

A prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) must be obtained before delivery for the HCPCS codes specified under Final Rule 1713 and evidence must be maintained in supplier files.
Suppliers must maintain documentation showing that all LCD Coverage Indications, Limitations, and Medical Necessity criteria have been met to support use of the KX modifier and must make such documentation available upon request.
When expecting denial as not reasonable and necessary, suppliers must use modifier GA if a properly executed Advance Beneficiary Notice (ABN) was obtained or modifier GZ if no valid ABN was obtained; documentation of the ABN must be retained.

Key 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.
HCPCS E0372 (powered pressure-reducing mattress overlay) is payable when an air pump/blower provides sequential inflation/deflation or low interface pressure, inflated cell height >= 3.5 inches, chamber geometry and cycling provide lift/reduce pressure/prevent bottoming out, surface reduces friction/shear, and R&N LCD criteria are met.
HCPCS E0373 (advanced nonpowered pressure-reducing mattress) is payable when individual cell height/design provide significantly more pressure reduction than group 1 mattresses and prevent bottoming out, total height >= 5 inches, surface reduces friction/shear, documented evidence of effectiveness exists, the product is listed on the PDAC PCL with a written CVR, can be placed on a hospital bed frame, and R&N LCD criteria are met.

16 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A55909, Billing and Coding: Wound Care

WPS-J5-L37228, Wound Care

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

WPS-J8-L37228, Wound Care

A53065, Billing and Coding: Outpatient Physical Therapy

A56459, Billing and Coding: Debridement Services

A57067, Billing and Coding: Outpatient Physical and Occupational Therapy Services

A57311, Billing and Coding: Physical Therapy - Home Health

A58565, Billing and Coding: Wound and Ulcer Care

AMBETTER-CP.MP.99, Wheelchair Seating

A52490, Pressure Reducing Support Surfaces - Group 2 - Policy Article

A53057, Billing and Coding: Home Health Occupational Therapy

A53058, Billing and Coding: Home Health Physical Therapy

A53064, Billing and Coding: Outpatient Occupational Therapy

`L89.42`, Pressure ulcer of contiguous site of back, buttock and hip, stage 2

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

L89.42, Pressure ulcer of contiguous site of back, buttock and hip, stage 2

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`L89.42`, Pressure ulcer of contiguous site of back, buttock and hip, stage 2