Does N28.1 require prior authorization?

No, N28.1 does not require prior authorization (high confidence). Covered without prior authorization.

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`N28.1`, Cyst of kidney, acquired

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.
This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.

Key Coverage Criteria

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).
Percutaneous aspiration with sclerotherapy (PAS) for symptomatic simple hepatic cysts (SHC)
Intravesical dextrose prolotherapy for bladder pain syndrome / interstitial cystitis (IC/BPS)
Percutaneous aspiration and sclerotherapy (AS/PAS) for symptomatic simple renal cysts (SRCs)
Endoscopic injection sclerotherapy (EIS) as a treatment option for acute esophageal variceal bleeding in cirrhosis (alternative to endoscopic variceal ligation)

5 Active Policies

AMBETTER-CG-Multi-Inher-DO.-Intel-Dis.-DD-2025.1, Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay

AETNA-CPB-0207, Prolotherapy and Sclerotherapy

AETNA-CPB-0492, Radiofrequency Tumor Ablation

A55336, Billing and Coding: Retroperitoneal Ultrasound

A56421, Billing and Coding: CT of the Abdomen and Pelvis

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N28.1, Cyst of kidney, acquired