L71.0 — Perioral dermatitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This policy provides billing, coding, and guideline information that complements the Local Coverage Determination (LCD) 'Cosmetic and Reconstructive Surgery' L33428; the full policy content is not included here, so specific documentation requirements (e.g., medical records, prior authorizations, forms) are not available in the provided excerpt.
- For reduction mammoplasty, the medical record must include height and weight of the beneficiary.
- For reduction mammoplasty, include a clinical evaluation documenting signs and/or symptoms ascribed to macromastia, therapies tried prior to surgery, and responses to those therapies.
- For reduction mammoplasty, document severity and impact on health-related quality of life using an accepted breast-specific questionnaire.
Key Coverage Criteria
- Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
- Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.
- ICD-10-CM Codes that Support Medical Necessity — Dermabrasion (CPT Codes 15780-15783): L71.0; L71.1; L71.8; T20.311A; T20.311D; T20.311S; T20.312A; T20.312D; T20.312S; T20.32XA; T20.32XD; T20.32XS; T20.33XA; T20.33XD; T20.33XS; T20.34XA; T20.34XD; T20.34XS; T20.35XA; T20.35XD; T20.35XS; T20.36XA; T20.36XD; T20.36XS; T20.37XA; T20.37XD; T20.37XS; T20.39XA; T20.39XD; T20.39XS; T20.711A; T20.711D; T20.711S; T20.712A; T20.712D; T20.712S; T20.72XA; T20.72XD; T20.72XS; T20.73XA; T20.73XD; T20.73XS; T2 [...]
- ICD-10-CM Codes that Support Medical Necessity — Abdominal Lipectomy/Panniculectomy (CPT Codes 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839 and 15847): A31.1; A43.1; A46; A48.0; B35.6; B35.8; B37.2; B95.0; B95.1; B95.2; B95.3; B95.4; B95.61; B95.62; B95.7; B96.0; B96.1; B96.3; B96.4; B96.5; B96.6; B96.7; B96.81; B96.82; B96.83; B96.89; I70.231; I70.238; I70.241; I70.248; I70.25; I70.431; I70.441; I70.45; I70.531; I70.541; I70.55; I70.631; I70.641; I70.65; I70.731; I70.741; I70.7 [...]
- ICD-10-CM Codes that Support Medical Necessity — Reconstructive Breast Surgery (CPT Codes 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396): C50.011; C50.012; C50.021; C50.022; C50.111; C50.112; C50.121; C50.122; C50.211; C50.212; C50.221; C50.222; C50.311; C50.312; C50.321; C50.322; C50.411; C50.412; C50.421; C50.422; C50.511; C50.512; C50.521; C50.522; C50.611; C50.612; C50.621; C50.622; C50.811; C50.812; C50.821; C50. [...]
- ICD-10-CM Codes that Support Medical Necessity — Reduction Mammoplasty (CPT Code 19318): Three diagnoses are required for payment (One primary and two secondary). Primary ICD-10-CM: N62; N65.1. Secondary ICD-10-CMs (two required from Group 5): L26; L30.4; L53.8; L54; L92.0; L95.1; L98.2; M25.511; M25.512; M40.04; M53.81; M53.82; M53.83; M53.84; M54.2; M54.6; M54.89; M54.9; M95.4; N64.4; R20.2; R21; Z85.3. [...]
9 Active Policies
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
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L39051 — Cosmetic and Reconstructive Surgery
J05
ANTHEM-MP-A050278 — Last Review Date
A56658 — Billing and Coding: Cosmetic and Reconstructive Surgery
A57221 — Billing and Coding: Plastic Surgery
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