R10.24 — Suprapubic pain
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
- Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
- Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.
- Claims must include the appropriate CPT code (88120 or 88121), 1 unit of service, and an appropriate ICD-10 diagnosis code for the clinical indication.
Key Coverage Criteria
- GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
- Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
- GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
- FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered when performed on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
- FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder cancer using urine specimens.
- Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
20 Active Policies
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L39713 — Trigger Point Injections
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A59553 — Billing and Coding: Trigger Point Injections
J05
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