N61.20 — Granulomatous mastitis, unspecified breast
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims must be submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s); services billed for conditions or diagnoses that are not covered under this Coverage Policy will be denied.
- When billing, providers must use the most appropriate codes as of the effective date of the submission.
- FDA note in document: ultrasound devices and probes are prescription devices and are to be used only with a physician's order (i.e., physician order is required).
- For evaluation/surveillance of women at increased risk for ovarian or endometrial cancer, documentation should support high-risk status (e.g., personal/family history consistent with hereditary cancer syndromes, BRCA mutation status, Lynch syndrome risk) as indicated by professional guidance cited in the policy.
Key Coverage Criteria
- Non-obstetrical transvaginal ultrasound is considered medically necessary for the evaluation of suspected pelvic pathology.
- Non-obstetrical transvaginal ultrasound is considered medically necessary for screening or surveillance of a woman at increased risk for ovarian or endometrial cancer.
- Evaluation of unexplained bleeding in the postmenopausal woman (TVUS can suggest presence of polyps, abnormal endometrial histology such as adenomatous hyperplasia, or cancer).
- Evaluation of a pelvic mass to provide information about the location of a pelvic mass relative to the ovary and uterus and to better delineate internal architectural characteristics.
- Evaluation of patients with acute pelvic pain (TVUS can help rule out ovarian primary source for acute pain when ovaries appear normal and no free intraperitoneal fluid is present).
- Evaluation of the infertile patient (role cited, particularly in management of controlled ovarian hyperstimulation) — note: infertility-related ultrasonography is addressed in a separate Cigna policy (Infertility Services).
2 Active Policies
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
ANTHEM-CG-LAB-29 — CG-LAB-29 Gamma Glutamyl Transferase Testing
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