Does E84.9 require prior authorization?

No, E84.9 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`E84.9`, Cystic fibrosis, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes under Final Rule 1713 and must be obtained prior to delivery per the LCD-related Standard Documentation Requirements (Article A55426).
The diagnosis code that justifies the need for the HFCWO item must be included on the claim.
The beneficiary's medical record must describe the underlying medical condition(s) causing accumulation of pulmonary secretions, prior and current treatment interventions (e.g., chest physiotherapy, postural drainage, medications, mechanical modalities such as in-exsufflation devices), and the effectiveness of those treatments; this information must be available upon request.
Suppliers must append modifier KX to HFCWO codes only when all LCD Coverage Indications/Limitations/Medical Necessity criteria are met; if not met, suppliers must append GA (if a valid ABN was obtained) or GZ (if no valid ABN was obtained); claim lines without KX, GA, or GZ will be rejected as missing information.

Key Coverage Criteria

High Frequency Chest Wall Oscillation (HFCWO) devices (HCPCS E0483) are covered under the Durable Medical Equipment benefit when the device is reasonable and necessary for the beneficiary per the related Local Coverage Determination (LCD) and all applicable Medicare statutory and regulatory requirements are met.
Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.
Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.

20 Active Policies

A57484, Billing and Coding: Vitamin D Assay Testing

WPS-J5-L34658, Vitamin D Assay Testing

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

A57736, Billing and Coding: Vitamin D Assay Testing

NGS-J6-L37535

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E84.9, Cystic fibrosis, unspecified