Does J45.998 require prior authorization?

No, J45.998 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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`J45.998`, Other asthma

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

When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.
When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.

Key Coverage Criteria

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.
RAST type tests are covered when medically necessary and supported by the related Local Coverage Determination (LCD) and current medical literature or standards of practice.
Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.

20 Active Policies

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J15-L34063, RAST Type Tests

J15

CGS-J18-L34063, RAST Type Tests

J18

CGS-J18-L40325, Allergy Diagnostic Testing

J18

WPS-J5-L36402, Allergy Testing

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J45.998, Other asthma