Does N64.9 require prior authorization?

No, N64.9 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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`N64.9`, Disorder of breast, unspecified

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.
ICD-10: N64.52 Nipple discharge [non-lactational sporadic nipple discharge]
Breast ductal lavage as an appropriate alternative to aspiration to diagnose members with non-lactational sporadic nipple discharge where the yield of cellular material from a direct nipple aspirate is too low to permit adequate cytological analysis.
Fiberoptic ductoscopy combined with cytology testing for diagnosing intra-ductal lesions in women with non-lactational sporadic nipple discharge accompanied by documented positive cytology.
Fiberoptic ductoscopy as a guide for resection of known breast intra-ductal cancer.

7 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

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0105, Magnetic Resonance Imaging (MRI) of the Breast

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N64.9, Disorder of breast, unspecified