Does J96.91 require prior authorization?

No, J96.91 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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`J96.91`, Respiratory failure, unspecified with hypoxia

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

Medical necessity for oxygen and oxygen equipment must be documented in the medical record according to the requirements of the related Local Coverage Determination (LCD).
A treating practitioner's order is required to justify a change in equipment modality, and a beneficiary must sign an Advance Beneficiary Notice (ABN) when electing an upgrade that may not be covered.
For a break-in-need that could restart a rental period, new medical necessity must be established and documented in the medical record.

Key Coverage Criteria

Oxygen and oxygen equipment are covered under the Durable Medical Equipment (DME) benefit when reasonable and necessary as documented per the related Local Coverage Determination (LCD) and all Medicare statutory and regulatory requirements are met.
When the reasonable useful lifetime (RUL) end date of stationary oxygen equipment occurs, the beneficiary may elect simultaneous replacement of both stationary and portable oxygen equipment, which starts a new 36-month rental period and a new RUL for both items.
If portable oxygen use begins after stationary equipment use began, payment for the portable equipment may continue beyond the end of stationary equipment payments until 36 monthly rental payments have been made for the portable equipment.
Cardiac catheterization and coronary angiography are covered when the medical record documents medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests that support the procedure.
Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.

14 Active Policies

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

NOVITAS-JH-L35049, Monitored Anesthesia Care

NOVITAS-JH-L35434, Oximetry Services

A57361, Billing and Coding: Monitored Anesthesia Care

NOVITAS-JL-L35049, Monitored Anesthesia Care

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

A56500, Billing and Coding: Cardiac Catheterization and Coronary Angiography

A56580, Billing and Coding: Computerized Axial Tomography (CT), Thorax

A56717, Billing and Coding: Respiratory Therapy (Respiratory Care)

A56784, Billing and Coding: Pulmonary Stress Testing

AMBETTER-CP.MP.242, Pulmonary Function Testing

A52514, Oxygen and Oxygen Equipment - Policy Article

`J96.91`, Respiratory failure, unspecified with hypoxia

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

J96.91, Respiratory failure, unspecified with hypoxia

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

`J96.91`, Respiratory failure, unspecified with hypoxia