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ICD-10-CM Q55.21, Polyorchism | No Prior Auth

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`Q55.21`, Polyorchism

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.
Refills based upon documentation in cycle sheets.
Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be required.
Semen analysis documentation: severe semen quantity or quality deficits require documentation on 2 separate occasions at least 2 weeks apart.

Key Coverage Criteria

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)
Iodine-deficiency related thyroid disorders and allied conditions (E01.8), subclinical iodine-deficiency hypothyroidism (E02), other hypothyroidism (E03.0 - E03.8)

2 Active Policies

AETNA-CPB-0327, Infertility

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

Related Codes

D27.0(2 policies)E25.0(2 policies)D25.0(2 policies)D25.9(2 policies)D39.0(2 policies)D39.2(2 policies)C81.00(2 policies)E25.9(2 policies)

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For use of gonadotropin therapy in males (hypogonadotropic hypogonadism), documentation of normalization of serum testosterone levels is required prior to administration of recombinant follitropin for induction of spermatogenesis (policy text: "after normal serum testosterone levels are reached").

Documentation of prior responses to gonadotropin stimulation should be used to individualize initial dosing in subsequent cycles (policy text: initial dose in subsequent cycles is individualized based on prior response).