Does J45.40 require prior authorization?

No, J45.40 does not require prior authorization (low confidence). No active coverage policies found for this code.

`J45.40`, Moderate persistent asthma, uncomplicated

ICD-10-CM

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Medical records must document the clinical indication and justification for omalizumab, including pre-treatment symptoms and objective spirometry (FEV1 and FEV1/FVC) consistent with moderate or severe persistent asthma when used for asthma.
Claims must document that administration occurred in a clinic or office by a physician or incident-to a physician and include evidence of post-administration observation and readiness to manage anaphylaxis.
Dose and frequency used must be supported by the FDA label or a recognized compendium citation in the medical record for covered uses or off-label compendia-supported uses.
When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.

Omalizumab is covered when administered by a physician or incident-to a physician’s service in a clinic or office setting.
Dose and frequency of omalizumab must follow the FDA-approved label or recognized compendia for the indicated or off-label use.
Use for patients with moderate or severe persistent asthma as defined by NHLBI clinical features and pre-treatment spirometry (FEV1 and FEV1/FVC thresholds by age) is the clinical context described in the policy.
Patients should receive omalizumab in a healthcare setting and be observed for an appropriate period after each treatment; administration must be by providers prepared to recognize and manage anaphylaxis.
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.

CGS-J15-L34063, RAST Type Tests

J15

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J15-L40056, Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

J15

CGS-J18-L40056, Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

J18

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