Z15.04 — Genetic susceptibility to malignant neoplasm of endometrium
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For surveillance: documentation of Lynch syndrome/genetic susceptibility to endometrial cancer (Z15.04) when endometrial surveillance is performed
- For sentinel lymph node mapping: documentation of a diagnosis of endometrial cancer (relevant pathology or diagnostic imaging/surgical findings) and indication for pathologic evaluation/surgical staging
- Pathology requisition and histologic examination results for endometrial biopsy specimens (adequacy of tissue must be documented as histology depends on sufficient tissue)
- When applicable, prior noninvasive evaluation results (e.g., transvaginal ultrasound endometrial thickness, prior negative biopsy with persistent symptoms) to justify further invasive evaluation per policy discussion
Key Coverage Criteria
- ICD-10 diagnoses listed as 'covered if selection criteria are met' (examples listed in policy): C54.1 - C54.9 (Malignant neoplasm of corpus uteri [except isthmus]); D06.0 - D07.0 (Carcinoma in situ of cervix uteri or other and unspecified parts of uterus); N85.00 - N85.02 (Endometrial hyperplasia); N92.1 (Excessive and frequent menstruation with irregular cycle); N92.4 (Excessive bleeding in the premenopausal period); N92.5, N93.8 (Other abnormal bleeding from female genital tract); N93.9 (Abnor [...]
- Endometrial biopsy (sampling) for histological tissue examination in the diagnostic evaluation of abnormal uterine bleeding in women suspected of having endometrial hyperplasia or endometrial carcinoma
- Endometrial biopsy (sampling) for endometrial cancer surveillance in women with Lynch syndrome
- Endometrial brush (Tao brush) as an acceptable alternative to an endometrial suction curette (e.g., Pipelle) for medically necessary endometrial sampling
- Sentinel lymph node mapping for pathologic evaluation and surgical staging in persons with endometrial cancer
- CPT/HCPCS codes listed as 'covered if selection criteria are met' when used for the above indications (examples listed in policy: 38792, 38900, 58100, 58110, 58558, C7503, 78195 when appropriate per selection criteria)
1 Active Policy
AETNA-CPB-0769 — Endometrial Cancer Screening, Diagnosis, and Prognosis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.