Does Q79.0 require prior authorization?

No, Q79.0 does not require prior authorization (high confidence). Covered without prior authorization.

`Q79.0`, Congenital diaphragmatic hernia

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
When submitting claims, linkage to an appropriate covered ICD-10 diagnosis code (e.g., I50.x for heart failure, J40–J47.x for chronic lower respiratory disease, R06.0x for dyspnea when used to distinguish HF from pulmonary disease) should be documented.
If CPT 83880 is billed, documentation should demonstrate that selection criteria for the covered indications (as stated in the policy) are met (clinical notes, emergency/urgent care evaluation, hospital admission notes, imaging or other cardiac testing as applicable).
For excluded indications (the long list of experimental/investigational uses), documentation supporting those uses will not render services payable — providers should document clinical rationale but should be aware tests for those purposes are considered not medically necessary per policy.

Measurement of plasma brain natriuretic peptide (BNP) to differentiate dyspnea due to heart failure from pulmonary disease (i.e., in patients presenting with dyspnea where heart failure versus pulmonary cause is in the differential).
NT-proBNP has certain diagnostic value for pulmonary arterial hypertension (PAH) secondary to systemic sclerosis (SSc-PAH) due to its better specificity and moderate sensitivity.
Measurement of plasma BNP to determine prognosis or disease severity in chronic heart failure.
Measurement of plasma BNP upon hospital admission to determine prognosis in persons with acutely decompensated heart failure.
CPT 83880 (natriuretic peptide) is covered if selection criteria are met (test covered as natriuretic peptide testing).
ICD-10 codes listed as covered diagnoses when selection criteria are met: I50.1 - I50.9 (Heart failure); J40 - J47.9 (Chronic lower respiratory diseases); R06.00 - R06.09 (Dyspnea) [note: dyspnea coverage limited — see limitations]; R06.82 (Tachypnea, not elsewhere classified) [note: coverage limited — see limitations].

ANTHEM-CG-SURG-92, Paraesophageal Hernia Repair

AETNA-CPB-0449, Fetal Surgery In Utero

AETNA-CPB-0546, Extracorporeal Membrane Oxygenation (ECMO)

AETNA-CPB-0618, Brain Natriuretic Peptide Testing

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

Ask Backwork about documentation requirements, denial risks, or coverage in your state.