Does N60.91 require prior authorization?

No, N60.91 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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`N60.91`, Unspecified benign mammary dysplasia 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

This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
All documentation must be maintained in the patient's medical record, legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner to support medical necessity.
Use diagnosis code Z41.1 (Encounter for cosmetic surgery) for cosmetic procedures and apply GY modifier for statutorily excluded or non-covered services when submitting for denial; include condition code 21 for no-payment non-covered claims as appropriate.

Key Coverage Criteria

Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
Mastectomy for gynecomastia is covered when glandular breast tissue consistent with true gynecomastia is documented, Grade III or IV classification (ASPS) is present, hormonal causes have been excluded by appropriate labs, medical treatment has failed for at least 6 months, and gynecomastia has persisted for at least 1 year.
Rhinoplasty is covered when medical record documents a condition requiring the procedure (including chronic nasal obstruction) with documentation of the cause of obstruction, appropriate diagnostic exams (e.g., anterior rhinoscopy, endoscopy, Cottle maneuver, CT) and prior conservative treatments with duration; septoplasty documentation must include surgical/pathology report when postoperative.
Rhinoplasty/Septoplasty to correct septal deformity that interferes with effective CPAP use is covered when medical management and duration of conservative therapy are documented showing interference with CPAP for treatment of an obstructive sleep disorder.

8 Active Policies

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

WPS-J5-L39051, Cosmetic and Reconstructive Surgery

A58774, Billing and Coding: Cosmetic and Reconstructive Surgery

WPS-J8-L39051, Cosmetic and Reconstructive Surgery

A59299, Billing and Coding: Cosmetic and Reconstructive Surgery

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

A56580, Billing and Coding: Computerized Axial Tomography (CT), Thorax

`N60.91`, Unspecified benign mammary dysplasia of right breast

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

N60.91, Unspecified benign mammary dysplasia of right breast

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`N60.91`, Unspecified benign mammary dysplasia of right breast