Does N61.20 require prior authorization?

No, N61.20 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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`N61.20`, Granulomatous mastitis, 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

Claims must be submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s); services billed for conditions or diagnoses that are not covered under this Coverage Policy will be denied.
When billing, providers must use the most appropriate codes as of the effective date of the submission.
FDA note in document: ultrasound devices and probes are prescription devices and are to be used only with a physician's order (i.e., physician order is required).

For evaluation/surveillance of women at increased risk for ovarian or endometrial cancer, documentation should support high-risk status (e.g., personal/family history consistent with hereditary cancer syndromes, BRCA mutation status, Lynch syndrome risk) as indicated by professional guidance cited in the policy.

When TVUS is used to evaluate postmenopausal bleeding or endometrial thickness, clinical documentation of symptoms (e.g., unexpected bleeding/spotting), indication for the exam, and any relevant measurement results (e.g., endometrial thickness) should be included to support medical necessity.

Key Coverage Criteria

Non-obstetrical transvaginal ultrasound is considered medically necessary for the evaluation of suspected pelvic pathology.
Non-obstetrical transvaginal ultrasound is considered medically necessary for screening or surveillance of a woman at increased risk for ovarian or endometrial cancer.
Evaluation of unexplained bleeding in the postmenopausal woman (TVUS can suggest presence of polyps, abnormal endometrial histology such as adenomatous hyperplasia, or cancer).
Evaluation of a pelvic mass to provide information about the location of a pelvic mass relative to the ovary and uterus and to better delineate internal architectural characteristics.
Evaluation of patients with acute pelvic pain (TVUS can help rule out ovarian primary source for acute pain when ovaries appear normal and no free intraperitoneal fluid is present).
Evaluation of the infertile patient (role cited, particularly in management of controlled ovarian hyperstimulation) — note: infertility-related ultrasonography is addressed in a separate Cigna policy (Infertility Services).

2 Active Policies

ANTHEM-CG-LAB-29, Gamma Glutamyl Transferase Testing

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

`N61.20`, Granulomatous mastitis, unspecified breast

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

N61.20, Granulomatous mastitis, unspecified breast

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

`N61.20`, Granulomatous mastitis, unspecified breast