Does D40.0 require prior authorization?

No, D40.0 does not require prior authorization (high confidence). Covered without prior authorization.

`D40.0`, Neoplasm of uncertain behavior of prostate

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
Documentation supporting the service must be available to Medicare upon request.
When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI.

Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
Urodynamic testing is covered when medical necessity is documented consistent with the related Local Coverage Determination (LCD) for Urodynamics.
Molecular biomarker testing to risk-stratify patients at increased risk for prostate cancer when allowed by MolDX Local Coverage Determination L39042.
Flow cytometry is covered to detect antigens used as therapeutic targets in neoplastic disease.

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34056, Urodynamics

J15

CGS-J15-L38997

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