Does D16.4 require prior authorization?

No, D16.4 does not require prior authorization (high confidence). Covered without prior authorization.

`D16.4`, Benign neoplasm of bones of skull and face

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.
Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.
Submitted medical record must support the use of the selected diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, ongoing documentation of any changes in course of treatment, and DHV as noted in the covered indications section.

Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy.
Services that meet the Medicare reasonable and necessary requirements per Local Coverage Determination (LCD) L35090 are covered when billed as reconstructive or medically necessary procedures.
Dermabrasion for treatment of rhinophyma is covered when the medical record documents the beneficiary's rhinophyma disease process supporting medical necessity.
Abdominal lipectomy/panniculectomy is covered when the pannus causes chronic intertrigo (skin irritation, infection, or chafing) and there is documented functional impairment (e.g., difficulty walking, exercising, or activities of daily living) after conservative treatment.
Removal of breast implants as reconstructive breast surgery is covered when the medical record describes a condition that makes implant removal medically reasonable and necessary.
Reduction mammaplasty is covered when the record documents height and weight, clinical signs/symptoms attributed to macromastia, prior therapies and responses, and contains operative and pathology reports with tissue weight removed from each breast and an age‑appropriate mammogram report.

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L36658, Proton Beam Therapy

J15

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

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