L12.31 — Epidermolysis bullosa due to drug
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.
- This policy applies to the following: seborrheic keratoses, skin tags, milia, molluscum contagiosum, sebaceous (epidermoid) cysts, moles (nevi), acquired hyperkeratosis (keratoderma) and viral warts (excluding condyloma acuminatum).
- Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record:
- A. The lesion has one or more of the following characteristics: bleeding
6 Active Policies
A57554 — Billing and Coding: Immune Globulins
J05
L34771 — Immune Globulins
J05
A57162 — Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
A57161 — Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
L34233 — Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
Related Codes
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