Does R06.01 require prior authorization?

No, R06.01 does not require prior authorization (high confidence). Code is covered without prior authorization.

`R06.01`, Orthopnea

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each echocardiography service requires a formal written report with interpretation retained in the record and copies of image documentation (paper or electronic) available for review.
A complete study must include M-mode and/or 2D measurements of LV end-diastolic diameter, LV end-systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion, and a qualitative description of LV function, or valid substitutes such as LV volumes, ejection fraction, and mass.
Doppler interrogation must state the modes used and provide both qualitative and quantitative information.

Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
Repeat echocardiographic studies are covered to monitor changes in cardiac structure or function when there is a change in clinical status or when disease progression is suspected.
BNP testing is covered when medical necessity is documented in the patient's record in accordance with the related Local Coverage Determination (LCD).
BNP testing performed as a diagnostic test should have the test result reported on the claim if known; if result is not known, report the symptoms that prompted the test.
CPT 78434 (gated SPECT) may be reported only in conjunction with CPT 78431 or CPT 78492 when billed for SPECT myocardial perfusion imaging (MPI).

CGS-J15-L33960, Cardiovascular Nuclear Medicine

J15

CGS-J15-L33943, B-type Natriuretic Peptide (BNP) Testing

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L33943, B-type Natriuretic Peptide (BNP) Testing

J18

CGS-J18-L33960

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