Does N80.399 require prior authorization?

No, N80.399 does not require prior authorization (high confidence). Covered without prior authorization.

`N80.399`, Endometriosis of the pelvic peritoneum, other specified sites, unspecified depth

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
CA-125 testing is consideredmedically necessaryforeitherclinical scenario (AorB)andthe following conditions (C):As part of initial evaluation for suspected or diagnosed disease;orTo determine whether residual tumor exists post-surgical therapy;andConditions:Appendiceal adenocarcinoma;orEndometrial cancer;orOvarian, primary peritoneal or fallopian tube cancer;orPancreatic adenocarcinoma;orPeritoneal mesothelioma;orUterine neoplasms (endometrial cancer and uterine sarcoma).
As part of initial evaluation for suspected or diagnosed disease;or
To determine whether residual tumor exists post-surgical therapy;and

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A52453, Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

ANTHEM-CG-LAB-32, Cancer Antigen 125 Testing

REGENCE-SUR218, Hysterectomy

A56421, Billing and Coding: CT of the Abdomen and Pelvis