Does E88.42 require prior authorization?

No, E88.42 does not require prior authorization (high confidence). Covered without prior authorization.

`E88.42`, MERRF syndrome

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

A specific written order (referral/prescription) by the physician or appropriate NPP must be on file for all respiratory care services.
Medical records must fully document that services were reasonable and medically necessary, with results and usage of the test documented in the record and available upon request.
Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's actual condition; listing a diagnosis code alone does not justify the test without supporting clinical context.
Referrals/orders must include clinical diagnoses and requested tests; indications in the primary medical record must be available for review.

Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
Pulmonary function tests (PFTs) represented by CPT codes 94070, 94200, 94640, 94726, 94727, and 94729 are covered when reasonable and medically necessary with supporting clinical documentation and a written order by a physician or appropriate NPP.
Spirometry (CPT 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726, 94727) is covered when clinically indicated and documented in the medical record.
Lung volume determination (CPT 94013, 94726, 94727, 94728) and diffusion capacity testing (CPT 94729) are covered when medically necessary and documented.
Pulmonary stress testing (CPT 94617, 94618, 94619, 94621) is covered when clinically indicated and supported by the medical record.
Device demonstration and/or evaluation (CPT 94664) is covered when used for device demonstration/evaluation purposes and documented as such in the medical record.

AMBETTER-CG-Metab-Endo-Mito-DO-2025.1, Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders

CIGNA-0136, Infant Nutritional Formula

A57224, Billing and Coding: Respiratory Care

Ask Backwork about documentation requirements, denial risks, or coverage in your state.