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ICD-10-CM L90.6, Striae atrophicae | No Prior Auth

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`L90.6`, Striae atrophicae

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must document the indication(s) supporting use of IVIG for each claim.
For indications where routine IVIG use is not indicated, the medical record must document prior interventions that were unsuccessful or reasons those interventions were not tolerated.
Documentation must support objective clinical response to IVIG for continued coverage.
Medical records must be made available to the Contractor upon request to substantiate coverage and payment.

Key Coverage Criteria

IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
Basal cell carcinoma (PDL and combined PDL+Nd:YAG have been studied; PDL showed variable results; combined PDL+Nd:YAG showed partial/histologic clearance in some small series).
Actinic keratoses if member has failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery
Genital warts when home therapy with either podophyllotoxin or imiquimod has failed
Granuloma faciale
Infantile hemangiomas

5 Active Policies

WPS-J5-L34771, Immune Globulins

J5

A57554, Billing and Coding: Immune Globulins

J5

WPS-J8-L34771, Immune Globulins

J8

AETNA-CPB-0559, Pulsed Dye Laser Treatment

AETNA-CPB-0735, Pulsed Radiofrequency

Related Codes

96365(3 policies)96366(3 policies)90393(3 policies)90396(3 policies)90371(3 policies)90375(3 policies)90376(3 policies)96372(3 policies)

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For infantile hemangiomas, granuloma faciale, pyogenic granuloma and other covered vascular lesions: clinical diagnosis documentation (e.g., physical exam, biopsy/pathology if performed), lesion size/location, prior treatments and response as applicable

For actinic keratoses: clinical documentation that the member failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery