Does Z72.0 require prior authorization?

No, Z72.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Z72.0`, Tobacco use

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Document patient age and exact smoking history including pack-year calculation (number of packs per day × years smoked) and date of smoking cessation (to confirm 'quit within past 15 years' where applicable).
Document that the patient is asymptomatic for lung cancer (screening is for asymptomatic individuals) and that screening discussion occurred (informed/shared decision-making) including core elements: benefits, uncertainties, and harms of LDCT screening (as recommended by the American Cancer Society).
Document that the patient is an appropriate candidate per the applicable eligibility criteria (e.g., meets NLST/USPSTF/ACCP age and smoking-history criteria or other program-defined high-risk criteria) and that the patient is in sufficiently good health to undergo potential curative therapy (i.e., no severe comorbidities that would preclude curative treatment or limit life expectancy).

ICD-10 code Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs) — covered if selection criteria are met.
ICD-10 code Z72.0 (Tobacco use [former smokers ages 50-80 years]) — covered if selection criteria are met.
ICD-10 code Z87.891 (Personal history of nicotine dependence [former smokers ages 50-80 years]) — covered if selection criteria are met.
Annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years (U.S. Preventive Services Task Force; Moyer, 2014).
Eligibility/High-risk population used in randomized trials (NLST): asymptomatic persons aged 55 to 74 years with a smoking history of at least 30 pack-years and current smoking or having quit within the last 15 years (National Lung Screening Trial [NLST] criteria).
Recommendation (American College of Chest Physicians, Detterbeck et al, 2013): For smokers and former smokers age 55 to 74 who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, annual screening with LDCT should be offered over both annual screening with chest x-ray (CXR) or no screening, but only in settings that can deliver the comprehensive care provided to National Lung Screening Trial (NLST) participants.

AETNA-CPB-0244, Skin and Soft Tissue Substitutes

AETNA-CPB-0380, Lung Cancer Screening

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