L57.3 — Poikiloderma of Civatte
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of infection when applicable (e.g., diagnosis of warts, molluscum contagiosum).
- Documentation that the lesion restricts vision or obstructs a body orifice, if that is the basis for removal.
- Clinical description consistent with suspicion for malignancy using ABCDE features (asymmetry, border, color, diameter >6 mm, evolving) where removal is for concern of malignancy.
- Biopsy/pathology report when biopsy has been performed showing premalignancy or malignancy (this is an explicit selection criterion).
Key Coverage Criteria
- Removal of acquired nevi (moles) when any of the selection criteria below are met.
- Removal of small congenital nevi (less than 1.5 cm) when any of the selection criteria below are met.
- Removal of cutaneous and subcutaneous neurofibromas when any of the selection criteria below are met.
- Removal of dermatofibromas when any of the selection criteria below are met.
- Removal of dermatosis papulosa nigra when any of the selection criteria below are met.
- Removal of acrochordon (skin tags) when any of the selection criteria below are met.
2 Active Policies
AETNA-CPB-0633 — Benign Skin Lesion Removal
ANTHEM-CG-LAB-21 — CG-LAB-21 Serum Iron Testing
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