Does Q34.1 require prior authorization?

No, Q34.1 does not require prior authorization (high confidence). Covered without prior authorization.

`Q34.1`, Congenital cyst of mediastinum

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.

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.
Unexplained abnormal respiratory signs (decreased breath sounds, over-inflation, cyanosis, chest deformity, wheezing or unexplained adventitial sounds).
Abnormal laboratory or imaging findings suggesting respiratory impairment (hypoxemia, hypercapnia, polycythemia, or abnormal chest radiographs).
Indirect assessment of the effect of systemic disease on pulmonary function (e.g., neuromuscular disease, connective tissue disease).
Preoperative risk assessment for patients with known or suspected airway dysfunction.

AMBETTER-CP.MP.242, Pulmonary Function Testing

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