Does Z90.10 require prior authorization?

No, Z90.10 does not require prior authorization (high confidence). Covered without prior authorization.

`Z90.10`, Acquired absence of unspecified breast and nipple

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The diagnosis code must be included on every claim for the prosthesis or related item.
A treating practitioner's new order explaining the need for a different type of breast prosthesis must be created and retained in the supplier's files whenever the patient's medical condition changes; the order need not be submitted with the claim.
Documentation created by an orthotist or prosthetist is considered part of the patient's medical record and may support the treating practitioner's documentation for prosthetics per Social Security Act §1834(h)(5).
For items subject to Final Rule 1713, a prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required and the WOPD must be in the supplier's files before delivery; absence of these documents results in denial.

Custom fabricated breast prostheses, including molded-to-patient-model prostheses (HCPCS L8035), are covered when individually made for a specific patient and meet LCD reasonable and necessary criteria.
External breast prostheses are covered under the Prosthetic Devices benefit when the prosthesis is reasonable and necessary and meets the requirements of the related Local Coverage Determination (LCD).
Adhesive skin support (HCPCS A4280) is covered when used to attach an external breast prosthesis directly to the chest wall and when R&N requirements are met.
Reconstructive breast surgery after a medically necessary mastectomy.
Reconstructive breast surgery after a medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, unresponsive to medical therapy).
Harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques (medically necessary).

ANTHEM-MP-A050277, ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANTHEM-SURG.00023, Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

AETNA-CPB-0031, Cosmetic Surgery and Procedures

AETNA-CPB-0097, External Breast Prosthesis

AETNA-CPB-0185, Breast Reconstructive Surgery

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