Does Z91.013 require prior authorization?

No, Z91.013 does not require prior authorization (high confidence). Covered without prior authorization.

`Z91.013`, Allergy to seafood

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document the clinical indication and justification for omalizumab, including pre-treatment symptoms and objective spirometry (FEV1 and FEV1/FVC) consistent with moderate or severe persistent asthma when used for asthma.
Claims must document that administration occurred in a clinic or office by a physician or incident-to a physician and include evidence of post-administration observation and readiness to manage anaphylaxis.
Dose and frequency used must be supported by the FDA label or a recognized compendium citation in the medical record for covered uses or off-label compendia-supported uses.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include appropriate patient identification (e.g., complete name, dates of service).

Omalizumab is covered when administered by a physician or incident-to a physician’s service in a clinic or office setting.
Dose and frequency of omalizumab must follow the FDA-approved label or recognized compendia for the indicated or off-label use.
Use for patients with moderate or severe persistent asthma as defined by NHLBI clinical features and pre-treatment spirometry (FEV1 and FEV1/FVC thresholds by age) is the clinical context described in the policy.
Patients should receive omalizumab in a healthcare setting and be observed for an appropriate period after each treatment; administration must be by providers prepared to recognize and manage anaphylaxis.
Allergy testing is covered when the medical record documents a history indicating the possible presence of allergy and the clinician selected a minimal number of tests/antigens based on patient-specific history and physician examination.
Allergy testing is covered when the medical record documents the test(s) used, the interpretation(s), and objective measurement of reaction size (wheal and erythema in mm) or a standardized in vivo grading system.

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

A57473, Billing and Coding: Allergy Testing

WPS-J5-L36402, Allergy Testing

A52448, Billing and Coding: Omalizumab and biosimilar, OMLYCLO (omalizumab-igec)

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