L97.101 Insurance Policy Changes

ICD-10 L97.101 is officially defined as "Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin." code L97.101 is referenced in 6 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code L97.101 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 17, 2026Medium impact
Electrical Stimulation for Chronic Ulcers (CPB 0680, reviewed 2026-10-14)
Aetna considers electrical stimulation medically necessary durable medical equipment for arterial ulcers, diabetic ulcers, Stage III or IV pressure ulcers, and venous stasis ulcers when it is used as adjunctive therapy after no measurable signs of healing for at least 30 days of conventional wound treatment. Courses exceeding 1 hour per day are not considered medically necessary, continued stimulation is not medically necessary if measurable healing is not shown within a 4-week treatment period or once the wound bed is 100% epithelialized, and electrical stimulation for chronic ulcers in the home setting is considered not medically appropriate. Aetna considers electrical stimulation experimental, investigational, or unproven for uses including prevention of ulcers and pressure sores, infected wounds, microcurrent as an adjunctive therapy, and the VeinoPlus device for venous ulcers.
Aetna · Identified Oct 1, 2026Medium impact
Pulmonary Hypertension Treatments and Selected Indications of Prostanoids (CPB 0184, reviewed 2026-09-02)
Aetna considers epoprostenol (Flolan, Veletri, or generic epoprostenol injection), iloprost inhalation (Ventavis), treprostinil inhalation (Tyvaso), and treprostinil injection (Remodulin or generic treprostinil injection) medically necessary for pulmonary arterial hypertension (PAH) when the initial approval criteria are met, and for pulmonary hypertension associated with interstitial lung disease (PH-ILD) for Tyvaso only. Aetna considers sotatercept-csrk (Winrevair) medically necessary for PAH in members 18 years of age and older when PAH is confirmed by right heart catheterization and the drug is used as add-on therapy alongside medications from at least two of the listed PAH drug classes. Continuation of these therapies is considered medically necessary for members who receive them through a previously authorized pharmacy or medical benefit and who show disease stability or disease improvement.
Aetna · Identified Aug 14, 2026Medium impact
Pulmonary Hypertension Treatments and Selected Indications of Prostanoids (CPB 0184, reviewed 2025-09-08)
Aetna's commercial policy sets the criteria for epoprostenol (Flolan, Veletri), iloprost inhalation (Ventavis), treprostinil inhalation (Tyvaso) and treprostinil injection (Remodulin) for pulmonary arterial hypertension (PAH, WHO Group 1), with Tyvaso also covered for pulmonary hypertension associated with interstitial lung disease (PH-ILD, WHO Group 3) when criteria are met. Sotatercept-csrk (Winrevair) is covered for members 18 years of age and older with PAH when they meet its add-on criteria, and atrial septostomy and balloon pulmonary angioplasty are covered for refractory severe PAH with right heart failure. Aetna considers pulmonary artery hypertension drugs experimental for pulmonary hypertension secondary to asthma, chronic obstructive pulmonary disease, congestive heart failure, ischemic vascular disease or lung resection.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Treatment of Varicose Veins/Venous Insufficiency
Blue Cross Blue Shield Association policy 7.01.124 (BCBSMS policy A.7.01.124) states that treatment of great or small saphenous veins, accessory saphenous veins, varicose tributaries, and perforator veins may be considered medically necessary for symptomatic varicose veins or venous insufficiency when specific criteria are met, and that saphenous vein treatment not meeting those criteria is considered cosmetic and investigational. The policy history shows an update dated 09/22/2026 that changed the policy description, made minor changes to the statements for great or small saphenous veins, accessory saphenous veins, and perforator veins, and re-worded the concurrent treatment statements for accessory saphenous veins and symptomatic varicose tributaries for clarity. Telangiectasia treatment is considered cosmetic and investigational.
Aetna · Identified Sep 29, 2026Low impact
Bio-Surgery: Medicinal Leech Therapy and Medical Maggots (CPB 0556, reviewed 2026-09-01)
Aetna's bio-surgery policy (CPB 0556, reviewed September 1, 2026) sets when medicinal leech therapy and medical maggots (bagged larval therapy) are covered, mainly for specific chronic wounds, flap and replant salvage. It lists many other uses, including knee and thumb osteoarthritis, low back pain and burns, as experimental, and the source gives a review date but no effective date.
Aetna · Identified Aug 15, 2026Low impact
Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries (CPB 0649, reviewed 2025-10-02)
This is Aetna Clinical Policy Bulletin 0649, reviewed October 2, 2025 and first found by PolicyChanges in August 2026, so it is historical material and the current version should be confirmed before acting. Aetna covers extracorporeal shock-wave therapy only for calcific tendinopathy of the shoulder with a calcium deposit of at least 1 cm lasting 6 months or more after conservative care has failed, and lists dozens of other musculoskeletal, wound and medical uses as experimental, investigational or unproven.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code L97.101?

There are 6 tracked policy changes affecting code L97.101, including updates from Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code L97.101?

Payers that have issued tracked updates for code L97.101 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code L97.101 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code L97.101. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code L97.101?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Electrical Stimulation for Chronic Ulcers (CPB 0680, reviewed 2026-10-14)

Pulmonary Hypertension Treatments and Selected Indications of Prostanoids (CPB 0184, reviewed 2026-09-02)

Pulmonary Hypertension Treatments and Selected Indications of Prostanoids (CPB 0184, reviewed 2025-09-08)

Treatment of Varicose Veins/Venous Insufficiency

Bio-Surgery: Medicinal Leech Therapy and Medical Maggots (CPB 0556, reviewed 2026-09-01)

Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries (CPB 0649, reviewed 2025-10-02)

What insurance policy changes affect code L97.101?

Which payers have updated policy for code L97.101?

How do I get notified when code L97.101 policy changes?

Why do payers change policies for code L97.101?