Does N42.30 require prior authorization?

No, N42.30 does not require prior authorization (high confidence). Covered without prior authorization.

`N42.30`, Unspecified dysplasia of prostate

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.
For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
Documentation supporting the service must be available to Medicare upon request.
When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI.

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.
Flow cytometry is covered for examination of body fluids (including peripheral blood and cerebrospinal fluid), bone marrow, and lymphoreticular tissues (lymph nodes, tonsil, spleen).
Peripheral blood and fine needle aspirate specimens are acceptable for flow cytometry to avoid more invasive diagnostic procedures.
Coverage decisions are governed by the associated Local Coverage Determination LCD L34215 and its specific coverage criteria.
ICD-10 codes listed as covered if selection criteria are met: C61; D07.5; D29.1; D40.0; N40.0 - N40.3; N42.30 - N42.39; R97.20 - R97.21; Z12.5; Z15.03; Z80.42; Z85.46.
PSA testing for men of all ages with signs or symptoms of prostate cancer.

A57427, Billing and Coding: Transrectal Ultrasound

NGS-J6-L33578, Transrectal Ultrasound

NGS-JK-L33578, Transrectal Ultrasound

A57689, Billing and Coding: Lab: Flow Cytometry

AETNA-CPB-0521, Prostate Cancer Screening

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