Does L98.411 require prior authorization?

No, L98.411 does not require prior authorization (high confidence). Covered without prior authorization.

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`L98.411`, Non-pressure chronic ulcer of buttock limited to breakdown of skin

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high 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.
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.

17 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-L37228, Wound Care

A55909, Billing and Coding: Wound Care

WPS-J8-L37228, Wound Care

A56658, Billing and Coding: Cosmetic and Reconstructive Surgery

A56697, Billing and Coding: Non-Invasive Vascular Studies

A57221, Billing and Coding: Plastic Surgery

A58565, Billing and Coding: Wound and Ulcer Care

ANTHEM-CG-MED-73, Hyperbaric Oxygen Therapy (Systemic/Topical)

AETNA-CPB-0556, Bio-Surgery: Medicinal Leech Therapy and Medical Maggots

AETNA-CPB-0587, Pancreas Kidney Transplantation

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

A53065, Billing and Coding: Outpatient Physical Therapy

A56459, Billing and Coding: Debridement Services

`L98.411`, Non-pressure chronic ulcer of buttock limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

L98.411, Non-pressure chronic ulcer of buttock limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`L98.411`, Non-pressure chronic ulcer of buttock limited to breakdown of skin