Does N80.C11 require prior authorization?

No, N80.C11 does not require prior authorization (high confidence). Covered without prior authorization.

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`N80.C11`, Endometriosis of the anterior abdominal wall, fascia and muscular layers

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.

Key Coverage Criteria

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).
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.

6 Active Policies

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

REGENCE-SUR218, Hysterectomy

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

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

`N80.C11`, Endometriosis of the anterior abdominal wall, fascia and muscular layers

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

N80.C11, Endometriosis of the anterior abdominal wall, fascia and muscular layers

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`N80.C11`, Endometriosis of the anterior abdominal wall, fascia and muscular layers