Does N93.9 require prior authorization?

No, N93.9 does not require prior authorization (high confidence). Covered without prior authorization.

`N93.9`, Abnormal uterine and vaginal bleeding, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical record must clearly document the specific clinical circumstances supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Pathology biopsy report must document diagnosis (e.g., simple/benign hyperplasia supports IUD; atypical/EIN requires poor surgical candidate documentation to justify IUD).
Transvaginal ultrasound (TVUS) evidence must be on file showing endometrial stripe > 4 mm.
For EIN/complex EH, documentation must support that the patient is a poor surgical candidate (medical comorbidities or surgical history) and counseling regarding options occurred.

Progestin-containing intrauterine device (IUD) delivering progestins over 5 years is a reasonable treatment for endometrial hyperplasia without atypia in patients presenting with abnormal uterine bleeding.
Progestin-containing IUD may be used when patients with endometrial hyperplasia are unable to tolerate oral megestrol or develop high-risk complications from oral megestrol.
Progestin-containing IUD may be used for patients with endometrial hyperplasia who are not reasonable surgical candidates or who wish to preserve fertility.
For atypical complex hyperplasia/EIN, nonsurgical management with a progestin-containing IUD is limited to patients for whom documentation shows they are poor surgical candidates.
ICD-10 diagnoses listed as 'covered if selection criteria are met' (examples listed in policy): C54.1 - C54.9 (Malignant neoplasm of corpus uteri [except isthmus]); D06.0 - D07.0 (Carcinoma in situ of cervix uteri or other and unspecified parts of uterus); N85.00 - N85.02 (Endometrial hyperplasia); N92.1 (Excessive and frequent menstruation with irregular cycle); N92.4 (Excessive bleeding in the premenopausal period); N92.5, N93.8 (Other abnormal bleeding from female genital tract); N93.9 (Abnor [...]
Endometrial biopsy (sampling) for histological tissue examination in the diagnostic evaluation of abnormal uterine bleeding in women suspected of having endometrial hyperplasia or endometrial carcinoma

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

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

AMBETTER-CP.MP.106, Endometrial Ablation

AMBETTER-CP.MP.97, Testing for Select Genitourinary Conditions

ANTHEM-CG-LAB-21

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