Does L97.416 require prior authorization?

No, L97.416 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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`L97.416`, Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis

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

The final report must include an impression or summary statement, a specific or differential diagnosis if appropriate, and recommendations for follow-up when clinically applicable.
All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be available to the contractor upon request.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.

Key Coverage Criteria

Doppler ultrasound (peripheral venous ultrasound) is the standard preoperative test to evaluate venous reflux in patients with chronic venous insufficiency.
CPT 93971 should be used to report either a limited bilateral duplex scan or a complete unilateral duplex scan for peripheral venous reflux evaluation.
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.
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.
Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A55909, Billing and Coding: Wound Care

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

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

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

WPS-J5-L37228, Wound Care

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

A56758, Billing and Coding: Non-Invasive Vascular Studies

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

NGS-J6-L33627, Non-Invasive Vascular Studies

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

WPS-J8-L37228, Wound Care

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

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

A52993, Billing and Coding: Peripheral Venous Ultrasound

NOVITAS-JL-L35451, Peripheral Venous Ultrasound

`L97.416`, Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

L97.416, Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`L97.416`, Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis