Prior authorization / coverage note — document indication and selection criteria

Certain CPT/HCPCS codes (for example, 38792, 38900, 58100, 58110, 58558, 78195 and selected molecular/pathology codes) are listed in the policy as covered when the policy’s selection/clinical criteria are met; when requesting coverage or authorization, document the diagnostic indication and which selection criteria apply.

• Support prior authorization requests with documentation of the clinical indication (e.g., abnormal uterine bleeding, surveillance for Lynch syndrome) and the specific selection criteria met.
• If submitting codes for SLN mapping or sentinel-node imaging (e.g., 38792, 38900, 78195), reference the clinical staging indication and intraoperative mapping technique used.

SLN mapping — prior authorization considerations and documentation

SLN biopsy/mapping for endometrial carcinoma is discussed as investigational/ needing further study in background reviews; when used, the policy notes SLN mapping should be supported by documentation of investigational status or trial enrollment where applicable.

• If using SLN mapping in a setting considered investigational at the time, document rationale (clinical trial enrollment or supporting evidence) when requesting authorization.
• Include details of injection technique (e.g., cervical ICG) and planned staging approach to support clinical justification.

Prior authorization — evidence summary does not specify payer mandates

The policy does not list payer-specific prior-authorization codes or mandates; it summarizes evidence supporting SLN mapping (standardized cervical ICG injection and high diagnostic accuracy) but does not convert that evidence into explicit authorization requirements.

• When seeking authorization for SLN mapping, include study-relevant technique details (ICG cervical injection, planned ultrastaging) and clinical staging indication since no payer-specific codes/mands are provided in the bulletin.
• Provide documentation of mapping method and expected pathology processing to align with evidence cited (e.g., hematoxylin & eosin with ultrastaging and cytokeratin IHC for negative SLNs).

No specific prior authorization requirements stated in this policy excerpt

The bulletin excerpts do not state specific prior authorization requirements for SLN mapping or for the molecular/biomarker tests described; do not assume automatic prior‑authorization rules from this policy text alone.

• If an individual payer (not documented in this policy excerpt) requires prior authorization, follow that payer’s administrative process and provide clinical documentation as noted in the policy.
• For investigational biomarker testing, include protocol/consent or research documentation if applicable.

No prior authorization specified for biomarker testing in these excerpts

The extracted sections do not describe any specific prior‑authorization requirements for biomarker testing; when ordering investigational biomarker or molecular assays, document study details and clinical rationale to support testing.

• Include study/sample details (assay type, sample size, marker panel) and a clinical interpretation plan in the record when investigational biomarkers are performed.
• Confirm and follow any separate payer-specific prior authorization processes that may apply to genetic/molecular testing.

Prior authorization note — bulletin is informational; verify payer rules

This Clinical Policy Bulletin is informational about benefits administration and does not state specific prior authorization mandates in the extracted portions; verify payer-specific authorization rules before submission.

• Treat the bulletin as guidance for clinical coverage stance; contact the member’s plan for any required prior authorization steps or forms.
• Document the clinical indication and selection criteria in the chart to support any authorization request.

No step‑therapy required for SLN mapping — treat as alternative staging strategy

No step therapy or sequential treatment requirements are described for SLN mapping; the policy discusses SLN mapping as an alternative staging strategy (often using ICG cervical injection) rather than a step in a therapy sequence.

• Do not interpret the policy as imposing step‑therapy; document the clinical staging indication and mapping technique when requesting authorization or submitting claims.
• If using SLN mapping instead of full lymphadenectomy, document rationale and planned intraoperative/pathology procedures.

No step‑therapy requirements for diagnostic/prognostic tests in excerpt

No step therapy requirements are described for diagnostic or prognostic modalities in this policy excerpt; ordering clinicians should document clinical indications and any investigational status when applicable.

• For molecular or experimental diagnostics, include research/protocol details and clinical rationale in the medical record to support medical necessity or investigational use.
• Follow payer-specific administrative rules for prior authorization or coverage determinations.

No step‑therapy for biomarker/molecular testing — document study details and limitations

No step therapy requirements are described for biomarker or molecular testing in the provided section; when ordering such tests, document study details, assay type, and clinical rationale in the record.

• Document sample size, assay platform, and identified markers when performing investigational biomarker testing.
• Provide justification for clinical use versus research and note limitations cited in the policy (small cohorts, heterogeneous methods).

Document diagnostic indication when billing endometrial sampling

Endometrial sampling codes (for example, CPT 58100, 58110, 58558) are covered when selection criteria are met; providers must document the diagnostic indication (e.g., abnormal uterine bleeding) to support medical necessity.

• When billing endometrial sampling, include clinical indication in the chart (abnormal uterine bleeding, surveillance for Lynch syndrome, postmenopausal bleeding, etc.).
• If billing for screening (ICD-10 Z12.79), note that this encounter code is listed as not covered in the policy and may be denied.

Document Lynch‑syndrome surveillance (annual sampling and TVUS starting 30–35 yrs)

For women with Lynch syndrome, document annual endometrial sampling and transvaginal ultrasound beginning at age 30–35, and include family/personal history or tumor testing consistent with Lynch syndrome to support surveillance coding and medical necessity.

• Document family and personal history and any tumor testing used to evaluate for Lynch syndrome.
• Record that surveillance is being performed annually beginning at age 30–35 as indicated by guidelines cited in the policy.

Document SLN mapping technique and pathology processing (ICG, ultrastaging, IHC)

When performing SLN mapping, document intraoperative technique (standardized cervical injection of indocyanine green when used), mapping results, and pathology processing (H&E staining with ultrastaging and cytokeratin IHC on negative SLNs) in the operative and pathology reports.

• Record injection tracer and site (e.g., ICG — cervical injection), number and laterality of mapped SLNs, and any completion lymphadenectomy performed.
• Include pathology protocol: H&E staining, ultrastaging, and immunohistochemistry for cytokeratin on negative SLNs as described in the FIRES study.

No explicit procedural authorization requirements stated — document clinical/test details

The extracted excerpts do not state explicit documentation or procedural authorization requirements beyond the clinical and technique details referenced in the evidence summaries; focus documentation on clinical indication, technique, and study/test details when applicable.

• For investigational biomarker tests, document study/sample details, assay type, and limitations to support interpretation and any investigational claims.
• Ensure operative and pathology reports fully describe mapping technique and specimen handling to align with evidence summaries.

Document study details for investigational biomarker testing (sample size, assay, markers, limitations)

When investigational biomarker testing is performed, document study details in the clinical record: sample sizes, assay type/platform, identified markers, and study limitations to support interpretation and potential research use.

• Record the assay platform (for example, HPLC-TQ/MS for targeted metabolomics), the markers tested (e.g., ceramides, acylcarnitines), and the reference study cohort size.
• Note limitations cited in the policy (small cohorts, heterogeneous methods) in the clinical record to contextualize test results.

Providers are responsible for medical decisions; bulletin is informational

Treating providers are solely responsible for medical advice and treatment; the Clinical Policy Bulletin is informational and does not replace clinical judgment or constitute a contract or offer of coverage.

• Make treatment decisions based on the patient’s clinical needs and current standards of care; use the bulletin to guide coverage discussions but confirm benefits with the payer.
• Keep complete documentation to support medical necessity and any coverage determinations.

Exclude screening code Z12.79 — billing as screening may be denied

Do not bill screening encounter code Z12.79 for endometrial cancer when the service is being provided as diagnostic or surveillance for symptoms/risk; the policy lists Z12.79 as not covered and claims billed as screening may be denied.

• If the patient has symptoms (e.g., any postmenopausal bleeding) or surveillance indications (e.g., Lynch syndrome), use the appropriate diagnostic or surveillance ICD-10 code rather than Z12.79.
• Review payor coverage guidance before submitting claims that might be interpreted as screening.

Escalate evaluation for persistent symptoms; biopsy indicated for any postmenopausal bleeding

If symptoms persist despite a negative outpatient endometrial biopsy, pursue further evaluation; in asymptomatic postmenopausal women an endometrial stripe <5 mm generally does not require biopsy, but any postmenopausal bleeding—even one drop—constitutes an indication for biopsy.

• Document persistence of symptoms when pursuing additional sampling or hysteroscopy with curettage.
• Record endometrial stripe measurement and rationale when deciding whether to proceed to biopsy in asymptomatic patients.

SLN mapping evidence present but no explicit prior‑authorization mandates in text

The policy provides evidence on SLN mapping accuracy and feasibility but does not specify provider prior‑authorization or documentation mandates for SLN mapping; follow local payer processes and document clinical justification and mapping technique.

• Provide technique and pathology details (ICG cervical injection, ultrastaging) when requesting authorization or submitting claims for SLN mapping.
• If the payer requires prior authorization, supply the evidence-based justification described in the policy (detection and diagnostic accuracy data).

No explicit denial triggers listed — missing documentation or non‑covered codes may cause denials

The excerpts do not identify explicit denial triggers for the procedures/tests discussed; however, lack of required documentation or use of codes listed as not covered (e.g., screening code Z12.79) may lead to denials.

• Ensure documentation of medical necessity and selection criteria when billing to avoid administrative denials.
• Avoid billing investigational biomarker tests with standard coverage codes unless payer guidance permits and documentation is provided.

Investigational biomarkers — no explicit coverage requirements stated; document details

The policy excerpts do not state specific authorization or coverage requirements for investigational biomarkers; treat these assays as investigational and provide full documentation of study/testing details and clinical rationale when ordered.

• Include assay method, markers tested, and study limitations in the medical record for investigational biomarkers.
• Confirm any separate payer preauthorization requirements for molecular or genetic tests prior to ordering.