L80, Vitiligo
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Darvadstrocel (per the described studies): pre-treatment work-up including trans-perineal ultrasound (TP-US), pelvic MRI, and colonoscopy to rule out active proctitis; documentation of prior failed conventional and/or surgical attempts and prior seton placement; operative notes documenting fistula curettage and closure of the internal opening.
- Leucopatch (DFU trials): documentation of diabetic foot ulcer characteristics (Wagner grade, duration >6 weeks), baseline ulcer area and serial ulcer area measurements (including run-in period demonstrating <50% reduction for trial eligibility), weekly application records, digital imaging of ulcer, and confirmation of complete epithelialization by an (ideally) independent/masked observer.
- SVF/dARVadstrocel/perianal cell therapies: documentation of fistula anatomy (MRI/TP-US), absence of abscess, prior interventions (setons, flaps), surgical technique (curettage, internal opening closure), cell product identity/lot/dose, route and location of injection, and follow-up clinical and radiologic assessment of fistula healing.
Key Coverage Criteria
- Platelet-poor plasma (PPP) or platelet-rich plasma (PRP) injection for all indications including (not an all-inclusive list): Achilles tendon ruptures / Achilles tendinopathy; alopecia areata (androgenetic alopecia); ankle sprain; anterior cruciate ligament (ACL) surgery; as adjunctive material to bone graft; avascular necrosis of the hip and the shoulder; carpometacarpal arthritis of the thumb; cerebral palsy; chronic wounds; Crohn's disease-related perianal fistula; discogenic low back pain; f [...]
- Adipose-tissue-derived stem cells (Habeo cell therapy) for the treatment of chondromalacia patellae, knee osteoarthritis, scleroderma (systemic sclerosis), and all other indications.
- Autologous cell-based therapy for critical lower limb ischemia.
- Autologous interleukin-1 receptor antagonist blood products for knee osteoarthritis.
- Autologous whole-blood or autologous serum acupoint injection therapy for chronic urticaria.
- Bone marrow-derived mesenchymal stromal cells administration for facet joint injections and for the treatment of avascular necrosis of the shoulder, Crohn's disease, and osteoarthritis.
4 Active Policies
AMBETTER-CP.MP.123, Laser Therapy for Skin Conditions
AETNA-CPB-0422, Vitiligo
AETNA-CPB-0427, Carbon Dioxide Laser
AETNA-CPB-0784, Blood and Adipose Tissue Derived Products for Selected Indications
Related Codes
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