N63.0 — Unspecified lump in unspecified breast
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For magnetic seed or SAVI SCOUT localization: documentation of depth and distance of seed/reflector relative to target on imaging (e.g., target-to-reflector distance), and any intra-operative probe localization findings.
- Documentation of diagnostic imaging demonstrating the abnormality (mammography, ultrasound, or MRI) and the lesion characteristics (non-palpable or difficult-to-palpate; e.g., lesion depth, mobility, size — particularly < 2 cm — or clustered microcalcifications).
- Clinical notes stating why palpation-guided biopsy is inadequate (for non-palpable or difficult-to-palpate lesions) and justification for image-guided minimally invasive biopsy method chosen (ABBI, stereotactic, US-guided, MRI-guided, vacuum-assisted, RSL/ROLL).
- For localization procedures (RSL/ROLL), documentation of the localization procedure and intended use to guide excisional biopsy or breast-conserving surgery; for radioactive seed use include tracking/chain-of-custody and retrieval documentation.
Key Coverage Criteria
- Minimally invasive image-guided breast biopsy procedures are medically necessary as alternatives to needle localization core surgical biopsy (NLBx) in members with abnormalities identified by mammography that are non-palpable or difficult to palpate (e.g., deep, mobile, small [< 2 cm], or composed of clustered microcalcifications).
- Advanced Breast Biopsy Instrument (ABBI) for non-palpable or difficult-to-palpate mammographically-identified breast abnormalities.
- MRI-guided core-needle biopsy for non-palpable or difficult-to-palpate mammographically-identified breast abnormalities.
- 19286 each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)
- Radioactive seed localization (RSL) or radio-guided occult lesion localization (ROLL) of non-palpable breast lesions for locating lesions to guide excisional biopsy or breast-conserving surgery.
- Stereotactically guided core-needle biopsy for non-palpable or difficult-to-palpate lesions identified by mammography.
4 Active Policies
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
AETNA-CPB-0269 — Breast Biopsy Procedures
AETNA-CPB-0517 — Breast Ductal Lavage and Fiberoptic Ductoscopy
ANTHEM-CG-SURG-88 — CG-SURG-88 Mastectomy for Gynecomastia
Related Codes
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