Does N04.0 require prior authorization?

No, N04.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

`N04.0` — Nephrotic syndrome with minor glomerular abnormality

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.

Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D56.1 - Beta thalassemia
ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.02 - Hb-SS disease with splenic sequestration

A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

J05

L37205 — Chemotherapy Drugs and their Adjuncts

J05

L40180 — Off-label Use of Rituximab and Rituximab Biosimilars

J06

A58921 — Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

J06

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