N90.69 — Other specified hypertrophy of vulva
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Indication for surgical intervention in lipedema: 'Surgical procedures are indicated if, despite thorough conservative treatment, symptoms persist, or if there is progression of clinical findings and/or symptoms.'
- BDD screening: 'Pre-operative screening of BDD patients is vital so that efficient psychiatric treatment can be initiated and patients are not subjected to surgical interventions that may be ineffective or even harmful.'
- Qwo clinical-trial measures (useful for documenting baseline and response): 'The primary efficacy endpoint was the proportion of 2-level multi-component responders at Day 71... A 2-level multi-component responder was defined as having an improvement of at least 2 levels of cellulite severity from baseline on both the Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and the Patient Reported Photonumeric Cellulite Severity Scale (PR-PCSS) in the target buttock.'
Key Coverage Criteria
- Eye (ocular) prostheses and surgical implantation/attachment - considered medically necessary when prosthesis criteria in CPB 0619 - Eye Prosthesis are met.
- Facial prosthesis and related implantation/attachment - considered medically necessary when CPB 0620 criteria are met.
- Hair transplant - considered medically necessary when performed to correct permanent hair loss clearly caused by disease or injury (hair transplants for male pattern baldness or age-related thinning in women are considered cosmetic).
- Testicular prostheses - considered medically necessary for replacement of congenitally absent testes or testes lost due to disease, injury, or surgery.
- Dermal filler injections for facial lipodystrophy syndrome due to antiretroviral therapy (HCPCS G0429) - covered when selection criteria are met.
- Procedures and CPT/HCPCS listed under 'CPT codes covered if selection criteria are met' and 'HCPCS codes covered if selection criteria are met' (examples include excision of benign lesions, grafting, dermabrasion, chemical peel codes, rhinoplasty/septoplasty codes, panniculectomy-related codes, certain prosthesis HCPCS) when the specific medical necessity/selection criteria referenced in the CPB or related CPBs are met.
1 Active Policy
AETNA-CPB-0031 — Cosmetic Surgery and Procedures
Related Codes
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