L73.0 — Acne keloid
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Treatment of a keloid is consideredmedicallynecessarywhen both of the following are present:
- There is documented evidence of significant functional impairment related to the keloid;and
- The treatment can be reasonably expected to improve the functional impairment.
- Treatment of a keloid with radiation therapy (up to 3 fractions) is consideredmedically necessaryas adjunct therapy following surgical excision (initiated within 3 days) when the medically necessary criteria for keloid removal are met.
- Treatment of a keloid isreconstructivewhen the keloid results in a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease.
- Treatment of a keloid with radiation therapy (up to 3 fractions) is consideredmedically necessaryas adjunct therapy following surgical excision (initiated within 3 days) when the reconstructive criteria for keloid removal are met.
1 Active Policy
ANTHEM-CG-SURG-31 — CG-SURG-31 Treatment of Keloids and Scar Revision
Related Codes
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