L12.30 — Acquired epidermolysis bullosa, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical records must clearly document medical necessity and an explicit rationale for why removal is not cosmetic when billing CPT 17106-17108.
- Coding and billing guidance must be used with the associated Local Coverage Determination; coverage details for CPT 11055-11057 are delineated in the Medicare Internet-Only Manual and should be followed for claims.
- Medical records must document the indication(s) supporting use of IVIG for each claim.
- For indications where routine IVIG use is not indicated, the medical record must document prior interventions that were unsuccessful or reasons those interventions were not tolerated.
Key Coverage Criteria
- Removal of benign skin lesions billed with CPT 17106, 17107, or 17108 is covered only when clinical records document medical necessity and explicitly state why the procedure is not cosmetic.
- Treatment of hyperkeratotic lesions (e.g., corns and calluses) billed with CPT 11055, 11056, or 11057 is covered as described in the Medicare Internet-Only Manual.
- IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
- Off-label use of rituximab or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).
- Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
- Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
10 Active Policies
L34771 — Immune Globulins
J05
A57554 — Billing and Coding: Immune Globulins
J05
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
L40180 — Off-label Use of Rituximab and Rituximab Biosimilars
Related Codes
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