Does L98.491 require prior authorization?

No, L98.491 does not require prior authorization (high confidence). Covered without prior authorization.

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`L98.491`, Non-pressure chronic ulcer of skin of other sites 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.

If CPT 97597 or 97598 is billed by a therapist while the patient is under a Home Health benefit, coverage depends on inclusion in the Home Health plan of care; if billed by a physician or non-physician practitioner it is paid under Part B even if the beneficiary has an active Home Health plan.

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.
A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.

10 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

WPS-J5-L37228, Wound Care

A55909, Billing and Coding: Wound Care

WPS-J8-L37228, Wound Care

A58565, Billing and Coding: Wound and Ulcer Care

AETNA-CPB-0017, Breast Reduction Surgery and Gynecomastia Surgery

AETNA-CPB-0649, Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries

A56459, Billing and Coding: Debridement Services

A57221, Billing and Coding: Plastic Surgery

`L98.491`, Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

L98.491, Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`L98.491`, Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin