Does S00.261A require prior authorization?

No, S00.261A does not require prior authorization (high confidence). Covered without prior authorization.

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`S00.261A`, Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter

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.

14 Active Policies

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34393, Ocular Photography - External

J18

WPS-J5-L34596, Immunizations

A55909, Billing and Coding: Wound Care

A56900, Billing and Coding: Immunizations

WPS-J5-L37228, Wound Care

WPS-J8-L37228, Wound Care

WPS-J8-L34596, Immunizations

A53065, Billing and Coding: Outpatient Physical Therapy

A56459, Billing and Coding: Debridement Services

AMBETTER-CP.VP.43, External Ocular Photography

A57068, Billing and Coding: Ocular Photography - External

`S00.261A`, Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

S00.261A, Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

`S00.261A`, Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter