N80.00 — Endometriosis of the uterus, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- - von Willebrand factor antigen (VWF:Ag), VWF activity measures (RCoF, collagen binding), VWF multimer analysis where available
- - VWF pro-peptide (VWFpp) in some studies
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
8 Active Policies
AETNA-CPB-0113 — Botulinum Toxin
AETNA-CPB-0501 — Gonadotropin-Releasing Hormone Analogs and Antagonists
AETNA-CPB-0530 — Transvaginal Ultrasonography
AETNA-CPB-0780 — ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP)
ANTHEM-CG-MED-84 — CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting
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