95012
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$19.71
Non-Facility
$19.71
Documentation Required
- 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).
- For HBT: documentation of a trial of a lactose-free diet for 2 weeks and persistence of symptoms after that trial (to justify HBT per medical necessity criteria)
Key Coverage Criteria
- 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
- ICD-10 diagnoses listed as covered when selection criteria are met: E73.0–E73.9 (lactose intolerance)
2 Active Policies
AETNA-CPB-0390 — Smell and Taste Disorders: Diagnosis
AETNA-CPB-0691 — Exhaled Breath Tests
Related Codes
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