Does J95.5 require prior authorization?

No, J95.5 does not require prior authorization (high confidence). Covered without prior authorization.

`J95.5`, Postprocedural subglottic stenosis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
Report overnight oximetry using CPT code 94762 on claims.
Documentation of lung transplant status or complications in the medical record (e.g., ICD-10 Z94.2 or T86.810-T86.819) to support medical necessity for home spirometry/telespirometry.
Documentation that home spirometry/telespirometry is being used specifically for monitoring lung function in a lung transplant recipient (clinical notes indicating purpose: early detection of infection/rejection or routine monitoring).

Home spirometry and telespirometry are considered medically necessary for lung transplant recipients (for monitoring lung function at home).
ICD-10 T86.810 - T86.819 (Complications of lung transplant) — covered when used for monitoring of lung function at home.
ICD-10 Z94.2 (Lung transplant status) — covered when used for monitoring of lung function at home.
CPT codes covered if selection criteria are met: 94014 (patient-initiated spirometric recording per 30-day period; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation), 94015 (recording: hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration), 94016 (physician review and interpretation only).
HCPCS code covered if selection criteria are met: E0487 (Spirometer, electronic, includes all accessories).
Pulmonary function testing (PFT) is medically necessary for members/enrollees aged ≥3 years when policy criteria are met.

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

AMBETTER-CP.MP.242, Pulmonary Function Testing

AETNA-CPB-0572, Home/Ambulatory Spirometry

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