L81.2 — Freckles
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For infantile hemangiomas, granuloma faciale, pyogenic granuloma and other covered vascular lesions: clinical diagnosis documentation (e.g., physical exam, biopsy/pathology if performed), lesion size/location, prior treatments and response as applicable
- For actinic keratoses: clinical documentation that the member failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery
- For genital warts: documentation that home therapy with podophyllotoxin or imiquimod has failed (e.g., treatment dates, agent used, clinical outcome)
- For verrucae (warts): documentation that at least two conventional therapies were tried and failed (list of therapies tried such as topical chemotherapy, curettage, electrodesiccation, cryotherapy with dates and results)
Key Coverage Criteria
- Basal cell carcinoma (PDL and combined PDL+Nd:YAG have been studied; PDL showed variable results; combined PDL+Nd:YAG showed partial/histologic clearance in some small series).
- Actinic keratoses if member has failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery
- Genital warts when home therapy with either podophyllotoxin or imiquimod has failed
- Granuloma faciale
- Infantile hemangiomas
- FDA-cleared for use in treatment of warts, port-wine stains, hemangiomas, hypertrophic scars, and telangiectasias.
1 Active Policy
AETNA-CPB-0559 — Pulsed Dye Laser Treatment
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