L97.101 — Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The CPB does not state specific, detailed documentation requirements; it indicates that CPT/ICD-10 codes are covered "if selection criteria are met." No explicit required medical record elements, prior-authorization items, or exact documentation checklists are provided in this document.
- Documentation that the member meets the transplanting institution's selection criteria; OR if no institution criteria exist, documentation that both required numeric criteria are met: calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min, AND documented ESRD with current dialysis or expectation of requiring dialysis within the next 12 months.
- Record of the Cockcroft-Gault calculation inputs (age, weight in kg, serum creatinine in mg/dL) or directly measured GFR values to support creatinine clearance/GFR determination.
Key Coverage Criteria
- Medicinal leech therapy is medically necessary for salvage of vascularly compromised flaps (muscle, skin, and fat tissue surgically removed from one part of body to another).
- Medicinal leech (Hirudo medicinalis) therapy is medically necessary for any of the following conditions: poor venous drainage (venous congestion/venous outflow obstruction).
- Medicinal leech therapy is medically necessary for salvage of vascularly compromised replants (limbs or other body parts re-attached after traumatic amputation).
- Medical maggots (larval therapy) are medically necessary for debridement of non-healing necrotic skin and soft tissue wounds including chronic diabetic foot ulcers.
- Medical maggots are medically necessary for debridement of neuropathic foot ulcers.
- Medical maggots are medically necessary for debridement of non-healing traumatic or post-surgical wounds.
6 Active Policies
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
AETNA-CPB-0556 — Bio-Surgery: Medicinal Leech Therapy and Medical Maggots
AETNA-CPB-0587 — Pancreas Kidney Transplantation
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
Related Codes
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