Does N63.42 require prior authorization?

No, N63.42 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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`N63.42`, Unspecified lump in left breast, subareolar

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

The patient’s medical record must document medical necessity supporting the related LCD (L33585), including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A clear clinical indication for the breast sonogram, breast MRI, or ductogram must be documented in both the medical record and the referral order.
The medical record must include a formal written report describing all views completed, the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.

Key Coverage Criteria

Breast sonography (CPT 76641, 76642) is covered when the medical record documents medical necessity per the related LCD (L33585); if performed bilaterally, report modifier 50 with CPT 76641 or 76642.
Breast MRI is covered only when billed with CPT code 77046, 77047, 77048, or 77049 and when medical necessity is documented per the related LCD (L33585).
Mammary ductogram/galactogram is covered only when billed with CPT 77053 or 77054 and medical necessity is documented per the related LCD (L33585); use CPT 19030 for contrast injection when billed separately.
For Part A facility billing, breast sonography should be billed using CPT 76641/76642; breast MRI may be billed using HCPCS C8903, C8905, C8906, C8908 or CPT 77046/77047; ductography should be billed using CPT 77053 or 77054.
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.

11 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

NGS-J6-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

NGS-JK-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A56448, Billing and Coding: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

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

ANTHEM-CG-SURG-88, Mastectomy for Gynecomastia

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0269, Breast Biopsy Procedures

AETNA-CPB-0517, Breast Ductal Lavage and Fiberoptic Ductoscopy

`N63.42`, Unspecified lump in left breast, subareolar

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

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N63.42, Unspecified lump in left breast, subareolar

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`N63.42`, Unspecified lump in left breast, subareolar