Does J18.9 require prior authorization?

No, J18.9 does not require prior authorization (high confidence). Covered without prior authorization.

`J18.9`, Pneumonia, unspecified organism

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for the HCPCS codes specified under Final Rule 1713; claims lacking these per the LCD-related Standard Documentation Requirements Article will be denied.
For add-on ensifentrine (J7601) therapy, the treating practitioner must document continuation of dual or triple maintenance therapy and either (a) history of continued COPD exacerbations within 12 months evidenced by hospitalization, ER visit, or new prescription for systemic glucocorticoids or antibiotics, or (b) during one exacerbation a combination of at least three clinical parameters (dyspnea VAS >5, respiratory rate >24 bpm, heart rate >95 bpm, oxygen saturation decline >=3% from baseline, or CRP >10 mg/L); also document persistent COPD-related dyspnea by persistent breathlessness or exercise limitation.
A diagnosis code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.

Nebulizers are covered under the Durable Medical Equipment (DME) benefit when the reasonable and necessary (R&N) requirements in the related Local Coverage Determination (LCD) are met.
Unfilled nebulizers (HCPCS A7007, A7017, E0585) filled with water or saline (A4217 or A7018) by the beneficiary or caregiver are an acceptable covered alternative.
Add-on ensifentrine (J7601) therapy to dual LABA+LAMA maintenance therapy or LABA+LAMA+ICS triple maintenance therapy for COPD is covered when the treating practitioner documents continuation of maintenance therapy and the required exacerbation or dyspnea criteria in the medical record.
Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT® or PLA code and an accompanying ICD-10-CM diagnosis that documents medical necessity in the patient record.
FDA-cleared/approved molecular infectious disease tests performed consistent with their intended use are covered without a DEX Z-code when billed with an appropriate supporting ICD-10-CM code.
A panel is a single test (single unit of service UOS=1) and is covered as one service even if it reports multiple pathogens or targets.

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J18-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J18

WPS-J5-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58761, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

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