N80.219 — Superficial endometriosis of unspecified fallopian tube
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be submitted in compliance with the Local Coverage Determination L39387 and applicable billing/coding guidelines.
- When submitting claims with discarded Part B drugs/biologicals from single-use vials or packages, document the discarded amount and reason in the patient’s medical record.
- Use the JW modifier on claims reporting discarded drugs and ensure supporting documentation in the medical record justifies the modifier.
- Medical record documentation must support the specific FDA-approved indication and diagnosis for which the LHRH analog is prescribed.
Key Coverage Criteria
- Administration of LHRH analogs is covered when prescribed, dosed, and administered consistent with FDA-approved labeling.
- Administration code 96402 may be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952, and J1954.
- Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.
- Leuprolide acetate is covered for treatment of endometriosis consistent with the FDA-approved labeling.
- Leuprolide acetate is covered for treatment of uterine fibroids (leiomyoma) consistent with the FDA-approved labeling.
- Leuprolide acetate is covered for advanced prostate cancer consistent with the FDA-approved labeling and NCCN guidance.
2 Active Policies
A59160 — Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
L39387 — Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Related Codes
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