Does Z91.040 require prior authorization?

No, Z91.040 does not require prior authorization (high confidence). Covered without prior authorization.

`Z91.040`, Latex allergy status

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.
When E/M services are reported with allergy testing, medical documentation of the separately identifiable E/M service must be present in the medical record and modifier -25 must be used.

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 patient has clinically significant allergic symptoms and conservative therapy has failed.
Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.

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

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

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