Does R10.21 require prior authorization?

No, R10.21 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`R10.21`, Pelvic and perineal pain right side

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

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.
The medical record must contain relevant medical history, physical examination, and results of pertinent diagnostic tests that fully support the medical necessity of each non-invasive vascular study.

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).
Non-invasive vascular studies (duplex scan, physiologic studies, plethysmography, transcranial Doppler) are covered when ordered by the treating or consulting practitioner and medically necessary to evaluate, diagnose, or manage vascular disease.
Initial autogenous access vessel mapping should be billed with HCPCS codes 93985 or 93986 and is covered when medically necessary for surgical planning.
Subsequent autogenous access mapping may be billed with CPT codes 93970 or 93971 when clinically indicated.

20 Active Policies

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

Have a follow-up question?

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

Ask Backwork about R10.21 Sign up free

R10.21, Pelvic and perineal pain right side