Does Z15.04 require prior authorization?

No, Z15.04 does not require prior authorization (high confidence). Covered without prior authorization.

`Z15.04`, Genetic susceptibility to malignant neoplasm of endometrium

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

For surveillance: documentation of Lynch syndrome/genetic susceptibility to endometrial cancer (Z15.04) when endometrial surveillance is performed
For sentinel lymph node mapping: documentation of a diagnosis of endometrial cancer (relevant pathology or diagnostic imaging/surgical findings) and indication for pathologic evaluation/surgical staging
Pathology requisition and histologic examination results for endometrial biopsy specimens (adequacy of tissue must be documented as histology depends on sufficient tissue)
When applicable, prior noninvasive evaluation results (e.g., transvaginal ultrasound endometrial thickness, prior negative biopsy with persistent symptoms) to justify further invasive evaluation per policy discussion

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
Endometrial biopsy (sampling) for endometrial cancer surveillance in women with Lynch syndrome
Endometrial brush (Tao brush) as an acceptable alternative to an endometrial suction curette (e.g., Pipelle) for medically necessary endometrial sampling
Sentinel lymph node mapping for pathologic evaluation and surgical staging in persons with endometrial cancer
CPT/HCPCS codes listed as 'covered if selection criteria are met' when used for the above indications (examples listed in policy: 38792, 38900, 58100, 58110, 58558, C7503, 78195 when appropriate per selection criteria)

AETNA-CPB-0769, Endometrial Cancer Screening, Diagnosis, and Prognosis

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