Does D05.01 require prior authorization?

No, D05.01 does not require prior authorization (high confidence). Covered without prior authorization.

`D05.01`, Lobular carcinoma in situ of right breast

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Submit CPT code 81520 on the claim to report the Prosigna® service.
Enter 1 unit of service (UOS) when billing CPT code 81520.
For Part B (professional) claims, enter the appropriate DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for these claim field/types: Loop 2400 or SV101-7 for 837P electronic claims or Box 19 for paper claims.
For Part A (institutional) claims, enter the appropriate DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for these claim field/types: Line SV202-7 for 837I electronic claims or Block 80 for the UB-04 claim form.

Report the Prosigna® breast cancer assay using CPT code 81520 when the test is performed per coverage criteria in LCD MolDX: Breast Cancer Assay: Prosigna® (L36811).
Lab-developed tests for inherited cancer syndromes in patients with cancer as described in Local Coverage Determination (LCD) L39040 are the services addressed by this billing/coding guidance.
Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
Mastectomy for gynecomastia is covered when glandular breast tissue consistent with true gynecomastia is documented, Grade III or IV classification (ASPS) is present, hormonal causes have been excluded by appropriate labs, medical treatment has failed for at least 6 months, and gynecomastia has persisted for at least 1 year.

CGS-J15-L36425, MolDX: Breast Cancer Assay: ProsignaÂ®

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

Ask Backwork about documentation requirements, denial risks, or coverage in your state.