Does N60.09 require prior authorization?

No, N60.09 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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`N60.09`, Solitary cyst of unspecified 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

Clinical indication documented in the medical record (e.g., preoperative staging, high-risk screening, evaluation of implant rupture, axillary metastasis with unknown primary, bloody nipple discharge, surveillance after breast cancer).
For pre-operative MRI, documentation of multidisciplinary discussion and rationale because MRI can change surgical management and may overestimate disease ('decisions regarding MR surveillance were made on a case-by-case basis and after discussion of potential benefits and harms').
Prior imaging reports (mammography, digital breast tomosynthesis, and/or ultrasound) documenting the equivocal/suspicious finding prompting MRI.
Relevant pathology/biopsy results when available (e.g., core biopsy confirming malignancy or atypia) to support preoperative or staging MRI.

Key Coverage Criteria

Newly diagnosed Paget's disease;
ICD-10 codes covered if selection criteria are met : C79.81 Secondary malignant neoplasm of breast
ICD-10 codes covered if selection criteria are met : D05.00 – D05.02, D05.80 - D05.92 Carcinoma in situ of breast
ICD-10 codes covered if selection criteria are met : N60.81 - N60.89 Other benign mammary dysplasias
ICD-10 codes covered if selection criteria are met : N64.52 Nipple Discharge
ICD-10 codes covered if selection criteria are met : N64.53 Retraction of nipple

2 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0105, Magnetic Resonance Imaging (MRI) of the Breast

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N60.09, Solitary cyst of unspecified breast