Does N84.0 require prior authorization?

No, N84.0 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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`N84.0`, Polyp of corpus uteri

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

Submit CPT code 58999 on the claim for the IUD insertion.
Use ICD-10 code N84.0 or codes N85.00–N85.02 on the claim to indicate endometrial hyperplasia.
Enter the phrase "hormone IUD" in the comment/narrative field of the CMS-1500 claim form or the equivalent electronic claim field.
Refills based upon documentation in cycle sheets.

Key Coverage Criteria

Insertion of a hormone-containing intrauterine device (IUD) to treat endometrial hyperplasia in patients with abnormal uterine bleeding who are unable to tolerate oral megestrol or are at high risk for complications of oral megestrol.
N98.1: Hyperstimulation of ovaries
N99.83: Residual ovary syndrome
Benign neoplasm and neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct (D35.2 - D35.3; D44.3 - D44.4)
Neoplasm of uncertain behavior of female genital organs (D39.0 - D39.2)
Neoplasm of uncertain behavior of other and unspecified male genital organs (D40.8 - D40.9)

4 Active Policies

CIGNA-0013, Endometrial Ablation

ANTHEM-CG-MED-84, Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

AETNA-CPB-0327, Infertility

A53043, Billing and Coding: Endometrial Hyperplasia Treatment

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N84.0, Polyp of corpus uteri