96421
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation of signs or symptoms that may be explained by bronchospasm.
- Documentation of abnormal pre-bronchodilator spirometry when used as the basis for post-bronchodilator testing.
- Documentation that reversibility of bronchospasm has not yet been demonstrated (or prior bronchodilator test results).
- Clinical documentation supporting the indication for lung volume testing, including that it is being used to evaluate type and degree of dysfunction, especially at initial evaluation.
Key Coverage Criteria
- Pulmonary function testing (PFT) is medically necessary for members/enrollees aged ≥3 years when policy criteria are met.
- Spirometry is medically necessary to evaluate symptoms, signs of impaired lung function, or abnormal laboratory tests, including unexplained dyspnea, wheezing, orthopnea, cough, or phlegm production.
- Unexplained abnormal respiratory signs (decreased breath sounds, over-inflation, cyanosis, chest deformity, wheezing or unexplained adventitial sounds).
- Abnormal laboratory or imaging findings suggesting respiratory impairment (hypoxemia, hypercapnia, polycythemia, or abnormal chest radiographs).
- Indirect assessment of the effect of systemic disease on pulmonary function (e.g., neuromuscular disease, connective tissue disease).
- Preoperative risk assessment for patients with known or suspected airway dysfunction.
1 Active Policy
AMBETTER-CP.MP.242 — Pulmonary Function Testing
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.