Does R09.1 require prior authorization?

No, R09.1 does not require prior authorization (high confidence). Covered without prior authorization.

`R09.1`, Pleurisy

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.
Claims must follow the complementary Local Coverage Determination (LCD L34430) and, when CPT 97000–97799 are used by PT/OT, must include documentation that the services meet the coverage and documentation requirements for physical or occupational therapy.
Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
Report overnight oximetry using CPT code 94762 on claims.

Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
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.

FIRST_COAST-L38918, Respiratory Pathogen Panel Testing

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JH-L38916, Respiratory Pathogen Panel Testing

NOVITAS-JH-L35049, Monitored Anesthesia Care

NGS-L39027

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