Does N04.1 require prior authorization?

No, N04.1 does not require prior authorization (high confidence). Covered without prior authorization.

`N04.1`, Nephrotic syndrome with focal and segmental glomerular lesions

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.
Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.

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).
MS testing is covered when performed in accordance with the applicable Local Coverage Determination (LCD) coverage guidelines for monoclonal gammopathy.
Mass spectrometry (MS) testing is covered when the medical record documents that the testing is expected to influence the treatment or management of the condition for which the test is ordered.
Serum mass spectrometry (MS), with concurrent serum or urine immunofixation electrophoresis (sIFE/uIFE), is covered to confirm initial detection of M-protein when there is an abnormal serum protein electrophoresis (SPEP) or abnormal serum free light-chain (sFLC) test.
Serum MS, with concurrent sIFE/uIFE, is covered to discriminate therapeutic monoclonal antibody(s) from endogenous M-protein(s) during patient monitoring.

NGS-J6-L39189, Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

A58921, Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

NGS-JK-L39189, Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

A55336, Billing and Coding: Retroperitoneal Ultrasound

A56380

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