L98.499 — Non-pressure chronic ulcer of skin of other sites with unspecified severity
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 of failure to respond to appropriate conservative therapies (examples provided: rest, ice application, and medications).
- Medical record evidence supporting that selection criteria were met prior to billing code 0101T (i.e., clinical notes, prior treatment attempts, imaging reports specifying deposit size and location).
- If claiming coverage under the CPB, supporting clinical documentation must link the ICD-10 diagnosis to the policy-covered indication (i.e., calcific tendinopathy of shoulder meeting the above criteria) and should avoid coding that the policy explicitly lists as not covered (e.g., subacromial impingement syndrome).
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
AMBETTER-CP.MP.109 — Panniculectomy
AETNA-CPB-0556 — Bio-Surgery: Medicinal Leech Therapy and Medical Maggots
AETNA-CPB-0587 — Pancreas Kidney Transplantation
AETNA-CPB-0649 — Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
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