Does N60.01 require prior authorization?

No, N60.01 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`N60.01`, Solitary cyst of right breast

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The patient’s medical record must document medical necessity supporting the related LCD (L33585), including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A clear clinical indication for the breast sonogram, breast MRI, or ductogram must be documented in both the medical record and the referral order.
The medical record must include a formal written report describing all views completed, the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.
For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim; for breast sonography, breast MRI, and ductogram, the treating/ordering physician NPI is required on the claim (report in CMS-1500 item 17a or electronic equivalent).

Key Coverage Criteria

Breast sonography (CPT 76641, 76642) is covered when the medical record documents medical necessity per the related LCD (L33585); if performed bilaterally, report modifier 50 with CPT 76641 or 76642.
Breast MRI is covered only when billed with CPT code 77046, 77047, 77048, or 77049 and when medical necessity is documented per the related LCD (L33585).
Mammary ductogram/galactogram is covered only when billed with CPT 77053 or 77054 and medical necessity is documented per the related LCD (L33585); use CPT 19030 for contrast injection when billed separately.
For Part A facility billing, breast sonography should be billed using CPT 76641/76642; breast MRI may be billed using HCPCS C8903, C8905, C8906, C8908 or CPT 77046/77047; ductography should be billed using CPT 77053 or 77054.
Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.

20 Active Policies

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J18-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J18

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

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N60.01, Solitary cyst of right breast