T86.829 — Unspecified complication of skin graft (allograft) (autograft)
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.
- "This treatment must be performed by a healthcare professional in an office or clinic setting." (explicit statement in policy text regarding TMR/PEMF procedure delivery).
- For surgical-adjunct uses described in trials (example ACDF), study-entry documentation included: radiographical evidence (CT-myelogram or MRI) of a compressed cervical nerve root, symptomatic radiculopathy appropriate to the compressed root that had failed to respond to non-operative management, and presence of risk factors for non-union (e.g., smokers >1 pack/day and/or multi-level fusions) — these criteria are cited in the text as trial inclusion criteria (may inform documentation if seeking medical necessity justification).
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.
3 Active Policies
AETNA-CPB-0175 — Pulsed Electromagnetic Stimulation
AETNA-CPB-0556 — Bio-Surgery: Medicinal Leech Therapy and Medical Maggots
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Related Codes
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