Does L89.94 require prior authorization?

No, L89.94 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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`L89.94`, Pressure ulcer of unspecified site, stage 4

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 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.
Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
Electromagnetic therapy (HCPCS G0329) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.

4 Active Policies

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

A52468, Pressure Reducing Support Surfaces - Group 3- Policy Article

A53065, Billing and Coding: Outpatient Physical Therapy

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

`L89.94`, Pressure ulcer of unspecified site, stage 4

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

L89.94, Pressure ulcer of unspecified site, stage 4

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

`L89.94`, Pressure ulcer of unspecified site, stage 4