Covered without prior authorization (high confidence)
Documentation Required
Medical record documentation of signs or symptoms that may be explained by bronchospasm.
Documentation of abnormal pre-bronchodilator spirometry when used as the basis for post-bronchodilator testing.
Documentation that reversibility of bronchospasm has not yet been demonstrated (or prior bronchodilator test results).
Clinical documentation supporting the indication for lung volume testing, including that it is being used to evaluate type and degree of dysfunction, especially at initial evaluation.
Key Coverage Criteria
Pulmonary function testing (PFT) is medically necessary for members/enrollees aged ≥3 years when policy criteria are met.
Spirometry is medically necessary to evaluate symptoms, signs of impaired lung function, or abnormal laboratory tests, including unexplained dyspnea, wheezing, orthopnea, cough, or phlegm production.