Does N28.84 require prior authorization?

No, N28.84 does not require prior authorization (high confidence). Covered without prior authorization.

`N28.84`, Pyelitis cystica

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.
Staging information (eg, T1a N0 M0 for renal allograft neoplasms in most series) and documentation of metastatic status (absence/presence of distant metastasis) where relevant.

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).
Removal of other primary or metastatic malignant neoplasms, when removal of the neoplasm may be curative, and the member is unable to tolerate surgical resection;
Radiofrequency ablation (RFA) for adrenal gland
Cancer bone pain, management of refractory bone pain in persons with cancer;
Malignant lung masses, in persons who are not candidates for surgical intervention;

ANTHEM-CG-LAB-30, Outpatient Laboratory-based Blood Glucose Testing

AETNA-CPB-0492, Radiofrequency Tumor Ablation

A55336, Billing and Coding: Retroperitoneal Ultrasound

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