Does Z40.01 require prior authorization?

No, Z40.01 does not require prior authorization (high confidence). Covered without prior authorization.

`Z40.01`, Encounter for prophylactic removal of breast

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Reduction mammaplasty is consideredmedically necessarywhen either of the following criteria (I or II) are met:
I. Individuals meeting BOTH of the following criteria (A and B):
Presence of one or more of the following:A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities;orSubma [...]
A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities;or
Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy;or
Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least 3 months of adequate conservative treatment.and

ANTHEM-CG-SURG-71, Reduction Mammaplasty

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