Does R05.4 require prior authorization?

No, R05.4 does not require prior authorization (high confidence). Covered without prior authorization.

`R05.4`, Cough syncope

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claims for swallowing studies should include documentation consistent with LCD L33449; this billing guideline is a complement to that LCD and providers should retain medical records supporting the medical necessity of the dysphagia evaluation.
A specific written order (referral/prescription) by the physician or appropriate NPP must be on file for all respiratory care services.
Medical records must fully document that services were reasonable and medically necessary, with results and usage of the test documented in the record and available upon request.
Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's actual condition; listing a diagnosis code alone does not justify the test without supporting clinical context.

Swallowing studies (videofluoroscopic or radiologic studies described by CPT 70370, 70371, or 74230) performed for evaluation or diagnosis of dysphagia are the intended covered service per this billing guideline and LCD L33449.
Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
Pulmonary function tests (PFTs) represented by CPT codes 94070, 94200, 94640, 94726, 94727, and 94729 are covered when reasonable and medically necessary with supporting clinical documentation and a written order by a physician or appropriate NPP.
Spirometry (CPT 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726, 94727) is covered when clinically indicated and documented in the medical record.
Lung volume determination (CPT 94013, 94726, 94727, 94728) and diffusion capacity testing (CPT 94729) are covered when medically necessary and documented.
Pulmonary stress testing (CPT 94617, 94618, 94619, 94621) is covered when clinically indicated and supported by the medical record.

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

WPS-J8-L36402, Allergy Testing

A57636, Billing and Coding: Duplex Scanning

FIRST_COAST-L33674, Duplex Scanning

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