L41.0 — Pityriasis lichenoides et varioliformis acuta
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- An in-home Ultraviolet B (UVB) light therapy delivery device is consideredmedically necessarywhen conditions A and B are met:
- The treatment is foroneof the following conditions:Atopic dermatitis, when topical treatment alone has failed;orCutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndrome;orPityriasis lichenoides;orPruritus of hepatic disease;orPruritus of renal failure;orPsoriasis, when topical treatment alone has failed;orVitiligo, when topical treatment alone has failed;and
- Atopic dermatitis, when topical treatment alone has failed;or
- Cutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndrome;or
- Pityriasis lichenoides;or
- Pruritus of hepatic disease;or
1 Active Policy
ANTHEM-CG-DME-41 — CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
Related Codes
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