Does N60.19 require prior authorization?

No, N60.19 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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`N60.19`, Diffuse cystic mastopathy 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

Pathology and oncologic records as applicable (e.g., cancer diagnosis, BRCA status, mastectomy specimen details) when reconstruction is performed for oncologic indications.
Pre-operative imaging and planning records when utilized: CTA or MRA for perforator mapping, MRI/CT when used for volumetric analysis, 3D surface imaging and any 3D-printed templates used for operative planning.
Documentation of prior or planned radiotherapy (pre-operative or post-operative XRT) and counseling regarding increased complication risk with EIBR when XRT present.

Key Coverage Criteria

Reconstructive breast surgery after a medically necessary mastectomy.
Reconstructive breast surgery after a medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, unresponsive to medical therapy).
Harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques (medically necessary).
Medically necessary procedures to correct breast asymmetry that is due to a medically necessary mastectomy or a medically necessary lumpectomy that results in a significant deformity (including medically necessary procedures on the non-diseased/contralateral breast to produce a symmetrical appearance).
Prompt repair of breast asymmetry due to trauma (subject to CPB 0031 - Cosmetic Surgery criteria for cosmetic disfigurement due to trauma).
Medically necessary breast reconstructive procedures including (explicitly listed): capsulectomy; capsulotomy; implantation of FDA-approved internal breast prosthesis; mastopexy; insertion of breast prostheses; use of tissue expanders; reconstruction with latissimus dorsi (LD) myocutaneous flap; Ruben’s flap; superficial inferior epigastric perforator (SIEP) flap; superior or inferior gluteal free flap; transverse upper gracilis (TUG) flap; transverse rectus abdominis myocutaneous (TRAM) flap; d [...]

5 Active Policies

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

`N60.19`, Diffuse cystic mastopathy of unspecified breast

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

N60.19, Diffuse cystic mastopathy of unspecified breast

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`N60.19`, Diffuse cystic mastopathy of unspecified breast