Does L97.423 require prior authorization?

No, L97.423 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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`L97.423`, Non-pressure chronic ulcer of left heel and midfoot 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

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.
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.
Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

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

A55909, Billing and Coding: Wound Care

WPS-J5-L35751, 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

`L97.423`, Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

L97.423, Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`L97.423`, Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle