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ICD-10-CM N89.5, Stricture and atresia of vagina | No Prior Auth

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`N89.5`, Stricture and atresia of vagina

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Evidence of staging, prior treatments, and clinical rationale when a referenced CPB or guideline is cited as the basis for coverage
Verification of member's benefit coverage regarding cosmetic exclusions when the intended treatment might be considered cosmetic
No documentation requirements are specified in this excerpt (no explicit statements about required medical records, prior test results, or clinical notes).
The excerpt repeatedly states codes are 'covered if selection criteria are met' — documentation demonstrating that the applicable selection criteria are met is required (selection criteria themselves are not included in this excerpt)

Key Coverage Criteria

Pelvic pain associated with endometriosis
Primary penile tumor (clinical stage Tis, Ta, and T1 Grade 1 to 2)
Hypertrophic scars and keloids (incl. postburn and pediatric hypertrophic burn scars)
Traumatic scars and contractures (including morphea-related contracture)
Individuals with melanoma who have in-transit metastases and palliative surgery is not feasible
Refractory plantar warts (verruca plantaris)

1 Active Policy

AETNA-CPB-0427, Carbon Dioxide Laser

Related Codes

B55.1(1 policies)C06.0(1 policies)C06.9(1 policies)D23.0(1 policies)D23.9(1 policies)F52.0(1 policies)F52.1(1 policies)B35.1(1 policies)

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For fractional ablative laser fenestration of burn and traumatic scars (CPT 0479T/0480T), the procedure description specifies 'for functional improvement' — documentation of functional impairment and justification for functional improvement should be provided (inferred from procedure description)

Clinical documentation must support the covered ICD-10 diagnosis submitted with the CPT/HCPCS code (e.g., clinical notes, diagnostic evaluation, prior treatments) — explicit documentation lists are not provided in this excerpt