Does L88 require prior authorization?

No, L88 does not require prior authorization (high confidence). Code is covered without prior authorization.

`L88`, Pyoderma gangrenosum

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

J18

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34771, Immune Globulins

WPS-J5-L37228, Wound Care

Ask Verity about documentation requirements, denial risks, or coverage in your state.