Does N40.1 require prior authorization?

No, N40.1 does not require prior authorization (high confidence). Covered without prior authorization.

`N40.1`, Benign prostatic hyperplasia with lower urinary tract symptoms

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

When required, the name and NPI of the referring/ordering physician must be reported on the claim.
The claim must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.
Providers should verify and comply with applicable NCCI and OPPS requirements prior to billing Medicare for these procedures.
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.

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.
Urodynamic testing is covered when medical necessity is documented consistent with the related Local Coverage Determination (LCD) for Urodynamics.
Procedures using devices that have been approved for marketing by the FDA (including 510(k) cleared devices) may be considered for Medicare coverage when the service is reasonable and necessary to treat illness or injury as determined by the A/B Medicare Administrative Contractors (A/B MACs).
Procedures performed within qualifying clinical trials that meet the National Coverage Determination (NCD) for Routine Costs in Clinical Trials (310.1) or within FDA-approved Investigational Device Exemption (IDE) trials may be covered for routine costs and otherwise reasonable and necessary services.
Transurethral waterjet ablation of the prostate is reasonable and necessary for treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) when prostate volume is 30–150 mL.
Patient has persistent moderate to severe LUTS despite maximal medical management with International Prostate Symptom Score (IPSS) ≥12.

CGS-J15-L34090, Laser Ablation of the Prostate

J15

CGS-J15-L34085, Post-Void Residual Urine and/or Bladder Capacity by Ultrasound

J15

CGS-J15-L34056, Urodynamics

J15

CGS-J15-L38378, Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)

J15

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