D48.60 — Neoplasm of uncertain behavior of unspecified breast
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
- Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
- Claims must include the appropriate CPT code, 1 unit of service (UOS), and the appropriate ICD-10-CM diagnosis code.
- Additional medical necessity documentation must be submitted when more than 24 markers are tested.
Key Coverage Criteria
- Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
- Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
- Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
- Flow cytometry is covered for examination of body fluids (including peripheral blood and cerebrospinal fluid), bone marrow, and lymphoreticular tissues (lymph nodes, tonsil, spleen).
- Peripheral blood and fine needle aspirate specimens are acceptable for flow cytometry to avoid more invasive diagnostic procedures.
- Coverage decisions are governed by the associated Local Coverage Determination LCD L34215 and its specific coverage criteria.
12 Active Policies
A57690 — Billing and Coding: Lab: Flow Cytometry
AETNA-CPB-0105 — Magnetic Resonance Imaging (MRI) of the Breast
AETNA-CPB-0269 — Breast Biopsy Procedures
AETNA-CPB-0717 — Analysis of Volatile Organic Compounds
ANTHEM-MP-A050278 — Last Review Date
Related Codes
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