Does J98.9 require prior authorization?

No, J98.9 does not require prior authorization (high confidence). Covered without prior authorization.

`J98.9`, Respiratory disorder, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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).
When billing CPT 94014 / 94015: documentation of program components described in the CPT code descriptors (reinforced education provided to the patient, transmission of spirometric tracings, data capture, analysis/trend analysis of transmitted data, periodic recalibration of device, and physician review and interpretation of the transmitted data).
When billing CPT 94016: documentation of physician review and interpretation of spirometric data (notes of review, interpretation and any resulting clinical actions).

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).

AETNA-CPB-0572, Home/Ambulatory Spirometry

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