Does N61.23 require prior authorization?

No, N61.23 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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`N61.23`, Granulomatous mastitis, bilateral 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

Documentation supporting services must be available to Medicare upon request.
The medical record must contain the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
All services ordered or rendered must be signed and dated; signed and dated office visit records or operative reports must be in the record.
A clear clinical indication for diagnostic mammogram, breast sonogram, breast MRI, or ductogram must be documented in the medical record and in the referral/order.

Key Coverage Criteria

Diagnostic mammography, breast sonography (echography), breast MRI, and ductography are covered when a clear clinical indication for the test is documented in the medical record and in the referral/order.
A diagnostic mammogram performed after an initial screening mammogram (conversion from screening to diagnostic) is allowable when the screening abnormality prompting additional views is documented in the record.
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.

5 Active Policies

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

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

J18

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

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

A56448

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N61.23, Granulomatous mastitis, bilateral breast