Does N04.0 require prior authorization?

No, N04.0 does not require prior authorization (high confidence). Covered without prior authorization.

`N04.0`, Nephrotic syndrome with minor glomerular abnormality

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.

Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
Off-label use of rituximab and rituximab biosimilars billed to Medicare should follow the local coverage policy DL38920.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.

CGS-J15-L38920, Off-label Use of Rituximab and Rituximab Biosimilars

J15

CGS-J18-L38920, Off-label Use of Rituximab and Rituximab Biosimilars

J18

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

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