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ICD-10-CM N80.219, Superficial endometriosis of unspecified fallopian tube | No Prior Auth

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`N80.219`, Superficial endometriosis of unspecified fallopian tube

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must be submitted in compliance with the Local Coverage Determination L39387 and applicable billing/coding guidelines.
When submitting claims with discarded Part B drugs/biologicals from single-use vials or packages, document the discarded amount and reason in the patient’s medical record.
Use the JW modifier on claims reporting discarded drugs and ensure supporting documentation in the medical record justifies the modifier.
All listed documentation items are required for review; failure to submit any may affect decision outcome.

Key Coverage Criteria

Administration of LHRH analogs is covered when prescribed, dosed, and administered consistent with FDA-approved labeling.
Administration code 96402 may be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952, and J1954.
Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.

2 Active Policies

REGENCE-SUR218, Hysterectomy

A59160, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

Related Codes

D25.9(2 policies)N80.03(2 policies)D25.1(2 policies)D25.2(2 policies)N80.01(2 policies)N80.02(2 policies)D25.0(2 policies)N80.111(2 policies)

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Submit history and physical/chart notes.

Document any conservative treatments provided, if applicable.