N40.0 — Benign prostatic hyperplasia without lower urinary tract symptoms
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When required, enter the test identifier or short narrative (e.g., 'Initial Work-Up …', 'ThyraMIR', 'Oncomine DX', 'ColonSeq', 'LungSeq', 'MyPRS') in the claim comment/narrative field (Part B: Loop 2400 NTE02 or SV101-7 for 5010A1 837P; Part A: Loop SV202-7 for 837I or Block 80 for UB04; paper: Box 19 or attachment).
- For Rosetta Cancer Origin and VeriStrat claims submit a brief 'Initial Work-Up …' comment (under 80 characters) indicating preliminary pathology/imaging or predictive-testing evaluation has been performed.
- For OVA1 claims enter 'The patient meets all 3 FDA OVA1 criteria' in the claim narrative (Loop 2400 NTE02, SV101-7, Loop SV202-7, Block 80, or Box 19 as applicable).
- Claims using CPT 81479 for specific biomarkers must include a description of the testing performed in the claim narrative/remarks.
Key Coverage Criteria
- Oncomine DX Test (CPT 0022U) is covered when billed with CPT 0022U and the claim narrative contains the identifier 'Oncomine DX'.
- Rosetta Cancer Origin Test (CPT 81479) is covered when conventional surgical pathology and/or imaging work-up is unable to identify a primary neoplastic site and an 'Initial Work-Up …' comment is submitted on the claim.
- VeriStrat assay (CPT 81538) is covered when a preliminary predictive testing evaluation has been performed prior to ordering and an 'Initial Work-Up …' comment is submitted on the claim.
- OVA1 proteomic assay (CPT 81503) is covered for women >18 years old who have an ovarian mass and have surgery planned; the claim must include the narrative 'The patient meets all 3 FDA OVA1 criteria'.
- PROGENSA PCA3 (CPT 81313) is covered for appropriate prostate indications when the claim contains 'PCA3' and one of the ICD-10-CM codes listed in ICD-10-CM Codes that Support Medical Necessity Group 9.
- MyPRS genetic expression profile testing (CPT 81479) is covered when 'MyPRS' is entered in box 19 (or electronic equivalent) and the claim includes one of the ICD-10-CM codes listed in ICD-10-CM Codes that Support Medical Necessity Group 24.
16 Active Policies
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
L35396 — Biomarkers for Oncology
J12
A52986 — Billing and Coding: Biomarkers for Oncology
J12
AETNA-CPB-0521 — Prostate Cancer Screening
Related Codes
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