Does N60.99 require prior authorization?

No, N60.99 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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`N60.99`, Unspecified benign mammary dysplasia 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

For magnetic seed or SAVI SCOUT localization: documentation of depth and distance of seed/reflector relative to target on imaging (e.g., target-to-reflector distance), and any intra-operative probe localization findings.
Documentation of diagnostic imaging demonstrating the abnormality (mammography, ultrasound, or MRI) and the lesion characteristics (non-palpable or difficult-to-palpate; e.g., lesion depth, mobility, size — particularly < 2 cm — or clustered microcalcifications).
Clinical notes stating why palpation-guided biopsy is inadequate (for non-palpable or difficult-to-palpate lesions) and justification for image-guided minimally invasive biopsy method chosen (ABBI, stereotactic, US-guided, MRI-guided, vacuum-assisted, RSL/ROLL).

For localization procedures (RSL/ROLL), documentation of the localization procedure and intended use to guide excisional biopsy or breast-conserving surgery; for radioactive seed use include tracking/chain-of-custody and retrieval documentation.

Pathology/cytology reports from the biopsy demonstrating diagnostic results (benign, atypia, in-situ, invasive) and any subsequent clinical plan (follow-up vs. excision) to support medical necessity.

For MRI-guided biopsies: MRI reports indicating lesion visualization and need for MRI guidance.

Key Coverage Criteria

Minimally invasive image-guided breast biopsy procedures are medically necessary as alternatives to needle localization core surgical biopsy (NLBx) in members with abnormalities identified by mammography that are non-palpable or difficult to palpate (e.g., deep, mobile, small [< 2 cm], or composed of clustered microcalcifications).
Advanced Breast Biopsy Instrument (ABBI) for non-palpable or difficult-to-palpate mammographically-identified breast abnormalities.
MRI-guided core-needle biopsy for non-palpable or difficult-to-palpate mammographically-identified breast abnormalities.
19286 each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)
Radioactive seed localization (RSL) or radio-guided occult lesion localization (ROLL) of non-palpable breast lesions for locating lesions to guide excisional biopsy or breast-conserving surgery.
Stereotactically guided core-needle biopsy for non-palpable or difficult-to-palpate lesions identified by mammography.

2 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0269, Breast Biopsy Procedures

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N60.99, Unspecified benign mammary dysplasia of unspecified breast