Does 19120 require prior authorization?

No, 19120 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 19120?

Medicare facility rate: $407.82. Non-facility rate: $573.16. Work RVU: 5.77.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

5.77

Facility

$407.82

Non-Facility

$573.16

Core needle biopsy or incisional biopsy pathology report documenting one of the listed diagnoses or findings
No specific documentation requirements, required medical records, test results, or clinical documentation are stated in the provided excerpt.
No explicit documentation requirements are included in this fragment.
Inferred (based on referenced NCD/LCD and Medicare Benefit Policy Manual): documentation of medical necessity (eg, operative reports, diagnosis supporting mastectomy, pathology reports, clinical notes indicating functional impairment or reconstructive need) is required per NCD/LCD standards and MAC rules.

Breast Reconstruction Following Mastectomy | 140.2
No explicit covered indications or covered diagnoses are stated in the provided excerpt.
Inferred subject matter: the policy pertains to coverage/clinical criteria for breast excision and mastectomy procedures (title-based inference only; no specific covered clinical scenarios provided in excerpt).
Humana and subsidiaries apply a Medicare Administrative Contractor's (MAC's) LCD to all requests (both Part A and Part B services) within the MAC's applicable geographic jurisdiction.
There are no NCDs and/or LCDs for excision and mastectomy for breast lesions or for prophylactic mastectomy.
There are LCDs that address gynecomastia.

BCBSTN-b0c9dcfb3b — Breast Reconstructive and Symmetry Surgery Following Mastectomy

HUMANA-BREAST-EXCISION-AND-MASTECTOMY-MA — Breast Excision and Mastectomy - Medicare Advantage

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