Does N60.11 require prior authorization?

No, N60.11 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`N60.11`, Diffuse cystic mastopathy 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

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.

Key Coverage Criteria

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
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.

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-L39506, Cosmetic and Reconstructive Surgery

J18

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

J18

WPS-J5-L39051, Cosmetic and Reconstructive Surgery

A58774, Billing and Coding: Cosmetic and Reconstructive Surgery

A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

NGS-J6-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

WPS-J8-L39051, Cosmetic and Reconstructive Surgery

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

NGS-JK-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A59299, Billing and Coding: Cosmetic and Reconstructive Surgery

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0097, External Breast Prosthesis

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

AETNA-CPB-0185, Breast Reconstructive Surgery

AETNA-CPB-0501, Gonadotropin-Releasing Hormone Analogs and Antagonists

A56448, Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

`N60.11`, Diffuse cystic mastopathy of right breast

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

N60.11, Diffuse cystic mastopathy of right breast

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`N60.11`, Diffuse cystic mastopathy of right breast