Does D05.11 require prior authorization?

No, D05.11 does not require prior authorization (high confidence). Covered without prior authorization.

`D05.11`, Intraductal carcinoma in situ of right breast

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

If bone metastasis (C79.51 or C79.52) is treated, the medical record must also contain the diagnosis of the primary malignant neoplasm and be available on request.
Medical records must include diagnostic information and lab results that support medical necessity, including documentation of specific signs and symptoms substantiating FDA labeled or off‑label use.
The record should indicate the patient was advised to take adequate calcium and vitamin D supplementation.
Diagnosis codes supporting medical necessity must be submitted on the claim, including breast cancer code plus bone loss code and a code documenting current adjuvant SERM or aromatase inhibitor therapy when applicable.

Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.
Bisphosphonate therapy is covered for bone metastasis (C79.51 or C79.52) provided the patient's record also contains a diagnosis of the primary malignant neoplasm.
In breast cancer patients receiving adjuvant selective estrogen receptor modulators or aromatase inhibitor therapy, bisphosphonates are covered when billed with an appropriate breast cancer diagnosis code and a bone loss diagnosis code documenting treatment indication.
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.

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

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

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

J15

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

J15

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