Does L97.111 require prior authorization?

No, L97.111 does not require prior authorization (high confidence). Covered without prior authorization.

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`L97.111`, Non-pressure chronic ulcer of right thigh limited to breakdown of skin

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.

Key Coverage Criteria

Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
Non-invasive vascular studies (duplex scan, physiologic studies, plethysmography, transcranial Doppler) are covered when ordered by the treating or consulting practitioner and medically necessary to evaluate, diagnose, or manage vascular disease.
Initial autogenous access vessel mapping should be billed with HCPCS codes 93985 or 93986 and is covered when medically necessary for surgical planning.
Subsequent autogenous access mapping may be billed with CPT codes 93970 or 93971 when clinically indicated.
Pre-surgical radial artery conduit mapping may be performed and accompanied by vein-mapping when either study shows insufficient conduits for multiple bypass procedures.

20 Active Policies

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

WPS-J5-L35761, Non-Invasive Peripheral Arterial Vascular Studies

WPS-J5-L37228, Wound Care

A55909, Billing and Coding: Wound Care

A57594, Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

A57593, Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies

WPS-J5-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

NGS-J6-L33627, Non-Invasive Vascular Studies

A56758, Billing and Coding: Non-Invasive Vascular Studies

WPS-J8-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

WPS-J8-L35761, Non-Invasive Peripheral Arterial Vascular Studies

WPS-J8-L37228, Wound Care

FIRST_COAST-L33693, Peripheral Venous Ultrasound

A57125, Billing and Coding: Peripheral Venous Ultrasound

NOVITAS-JH-L35451, Peripheral Venous Ultrasound

NGS-JK-L33627, Non-Invasive Vascular Studies

NOVITAS-JL-L35451, Peripheral Venous Ultrasound

`L97.111`, Non-pressure chronic ulcer of right thigh limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

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L97.111, Non-pressure chronic ulcer of right thigh limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`L97.111`, Non-pressure chronic ulcer of right thigh limited to breakdown of skin