Does L97.203 require prior authorization?

No, L97.203 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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`L97.203`, Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

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

For CPT 97032, document the type of electrical stimulation (including 'manual'/'attended'), area(s) treated, and if used for muscle weakness provide objective strength ratings and functional deficits; if used for pain provide pain rating, pain location, and effect on function.
For HCPCS G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures showing impact on pain intensity/location/functional impact and/or swelling.
For non-implantable pelvic floor stimulation, document cognitive intactness, patient motivation, and a failed documented trial of PME training (defined as no clinically significant improvement after 4 weeks of an ordered PME plan).

Key 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.
Unattended electrical stimulation for wound management (HCPCS G0281) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that have not shown measurable healing after 30 days of conventional care.
Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.

3 Active Policies

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

A53065, Billing and Coding: Outpatient Physical Therapy

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

`L97.203`, Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

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L97.203, Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`L97.203`, Non-pressure chronic ulcer of unspecified calf with necrosis of muscle