Does D05.00 require prior authorization?

No, D05.00 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D05.00` — Lobular carcinoma in situ of unspecified breast

ICD-10-CM

No Prior Auth Required

Code is 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.
When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.

A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

L39040 — MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

A59926 — Billing and Coding: Molecular Pathology Procedures

J06

L35000 — Molecular Pathology Procedures

J06

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