Does Z11.52 require prior authorization?

No, Z11.52 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z11.52`, Encounter for screening for COVID-19

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

No explicit documentation requirements are stated in this Clinical Policy Bulletin.
Claims must demonstrate that selection criteria are met for covered CPT codes (e.g., 91065 and 95012) — supporting clinical records, history, and relevant prior conservative treatment (such as the 2-week lactose‑free diet for HBT)
When a test is billed, the medical record should support the specific covered indication listed in the policy (e.g., lactose intolerance symptoms after dietary trial, or asthma evaluation/monitoring) and include relevant clinical notes, prior treatment documentation, diagnosis codes, and age where applicable
For studies of OSA biomarkers: OSA diagnosis confirmed with a full overnight or home-based PSG (polysomnography) was required in retained studies (Canto Gde et al 2015).

Key Coverage Criteria

None specified. Aetna considers the analysis of volatile organic compounds experimental and investigational for the indications listed below (see Limitations).
Measurement of exhaled nitric oxide (FeNO) for evaluation of asthma
Hydrogen breath testing (HBT) for evaluation of suspected lactose intolerance/deficiency after a 2-week trial of a lactose-free diet and symptoms of lactose intolerance persist
Measurement of exhaled nitric oxide (FeNO) for monitoring response to long-term control therapy in members aged 5 years and older
CPT 91065 (Breath hydrogen or methane test) covered when selection criteria are met
CPT 95012 (Nitric oxide expired gas determination) covered when selection criteria are met

3 Active Policies

CIGNA-0557, COVID-19: In Vitro Diagnostic Testing

AETNA-CPB-0691, Exhaled Breath Tests

AETNA-CPB-0717, Analysis of Volatile Organic Compounds

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Z11.52, Encounter for screening for COVID-19