L97.919 — Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity
ICD-10-CM
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- The PA request must reflect the submitted prescription.
- The PA request must document the factors below in order to meet criteria (specific required factors not included in this document chunk).
- Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the member's overall health status;
- Appropriate medical history related to the current wound;
Key Coverage Criteria
- Wounds for which home health agency involvement is or is not present (PA must note whether a home health agency is involved).
- An approved home health agency must be involved in the care of the member for consideration of approval for wound care supplies.
- The prescription must be updated for any extensions to be granted.
- Stage III or IV chronic, nonhealing wound, such as a pressure, venous stasis, diabetic ulcer
- Postsurgical wound dehiscence
- Non-adhering skin grafts
1 Active Policy
HUMANA-WOUND-CARE-LA-MEDICAID — Wound Care - MEDICAID - LOUISIANA
Related Codes
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