R99, Ill-defined and unknown cause of mortality
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical indication documented in the medical record (e.g., preoperative staging, high-risk screening, evaluation of implant rupture, axillary metastasis with unknown primary, bloody nipple discharge, surveillance after breast cancer).
- For pre-operative MRI, documentation of multidisciplinary discussion and rationale because MRI can change surgical management and may overestimate disease ('decisions regarding MR surveillance were made on a case-by-case basis and after discussion of potential benefits and harms').
- Prior imaging reports (mammography, digital breast tomosynthesis, and/or ultrasound) documenting the equivocal/suspicious finding prompting MRI.
- Relevant pathology/biopsy results when available (e.g., core biopsy confirming malignancy or atypia) to support preoperative or staging MRI.
Key Coverage Criteria
- Newly diagnosed Paget's disease;
- ICD-10 codes covered if selection criteria are met : C79.81 Secondary malignant neoplasm of breast
- ICD-10 codes covered if selection criteria are met : D05.00 – D05.02, D05.80 - D05.92 Carcinoma in situ of breast
- ICD-10 codes covered if selection criteria are met : N60.81 - N60.89 Other benign mammary dysplasias
- ICD-10 codes covered if selection criteria are met : N64.52 Nipple Discharge
- ICD-10 codes covered if selection criteria are met : N64.53 Retraction of nipple
1 Active Policy
AETNA-CPB-0105, Magnetic Resonance Imaging (MRI) of the Breast
Related Codes
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