Does T85.44XS require prior authorization?

No, T85.44XS 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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`T85.44XS`, Capsular contracture of breast implant, sequela

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

The patient’s medical record must document medical necessity supporting the related LCD (L33585), including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A clear clinical indication for the breast sonogram, breast MRI, or ductogram must be documented in both the medical record and the referral order.
The medical record must include a formal written report describing all views completed, the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.

Key Coverage Criteria

Breast sonography (CPT 76641, 76642) is covered when the medical record documents medical necessity per the related LCD (L33585); if performed bilaterally, report modifier 50 with CPT 76641 or 76642.
Breast MRI is covered only when billed with CPT code 77046, 77047, 77048, or 77049 and when medical necessity is documented per the related LCD (L33585).
Mammary ductogram/galactogram is covered only when billed with CPT 77053 or 77054 and medical necessity is documented per the related LCD (L33585); use CPT 19030 for contrast injection when billed separately.
For Part A facility billing, breast sonography should be billed using CPT 76641/76642; breast MRI may be billed using HCPCS C8903, C8905, C8906, C8908 or CPT 77046/77047; ductography should be billed using CPT 77053 or 77054.
Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.

12 Active Policies

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

WPS-J5-L39051, Cosmetic and Reconstructive Surgery

A58774, Billing and Coding: Cosmetic and Reconstructive Surgery

A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

NGS-J6-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

WPS-J8-L39051, Cosmetic and Reconstructive Surgery

NGS-JK-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A59299, Billing and Coding: Cosmetic and Reconstructive Surgery

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

A56658, Billing and Coding: Cosmetic and Reconstructive Surgery

A57221, Billing and Coding: Plastic Surgery

`T85.44XS`, Capsular contracture of breast implant, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

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T85.44XS, Capsular contracture of breast implant, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`T85.44XS`, Capsular contracture of breast implant, sequela