Does N85.01 require prior authorization?

No, N85.01 does not require prior authorization (high confidence). Covered without prior authorization.

`N85.01`, Benign endometrial hyperplasia

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.
Submit CPT code 58999 on the claim for the IUD insertion.

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).
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.
Progestin-containing (hormone) IUD insertion may be approved for Medicare beneficiaries diagnosed with simple endometrial hyperplasia without atypia (ICD-10 N85.01).
Progestin-containing (hormone) IUD insertion may be approved for Medicare beneficiaries with endometrial hyperplasia, unspecified (ICD-10 N85.00).

A55951, Billing and Coding: Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting)

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

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

A58649, Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999

Ask Backwork about documentation requirements, denial risks, or coverage in your state.