A31.2 — Disseminated mycobacterium avium-intracellulare complex (DMAC)
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When submitting claims, linkage to an appropriate covered ICD-10 diagnosis code (e.g., I50.x for heart failure, J40–J47.x for chronic lower respiratory disease, R06.0x for dyspnea when used to distinguish HF from pulmonary disease) should be documented.
- If CPT 83880 is billed, documentation should demonstrate that selection criteria for the covered indications (as stated in the policy) are met (clinical notes, emergency/urgent care evaluation, hospital admission notes, imaging or other cardiac testing as applicable).
- For excluded indications (the long list of experimental/investigational uses), documentation supporting those uses will not render services payable — providers should document clinical rationale but should be aware tests for those purposes are considered not medically necessary per policy.
Key Coverage Criteria
- Measurement of plasma brain natriuretic peptide (BNP) to differentiate dyspnea due to heart failure from pulmonary disease (i.e., in patients presenting with dyspnea where heart failure versus pulmonary cause is in the differential).
- NT-proBNP has certain diagnostic value for pulmonary arterial hypertension (PAH) secondary to systemic sclerosis (SSc-PAH) due to its better specificity and moderate sensitivity.
- Measurement of plasma BNP to determine prognosis or disease severity in chronic heart failure.
- Measurement of plasma BNP upon hospital admission to determine prognosis in persons with acutely decompensated heart failure.
- CPT 83880 (natriuretic peptide) is covered if selection criteria are met (test covered as natriuretic peptide testing).
- ICD-10 codes listed as covered diagnoses when selection criteria are met: I50.1 - I50.9 (Heart failure); J40 - J47.9 (Chronic lower respiratory diseases); R06.00 - R06.09 (Dyspnea) [note: dyspnea coverage limited — see limitations]; R06.82 (Tachypnea, not elsewhere classified) [note: coverage limited — see limitations].
2 Active Policies
CIGNA-0538 — Flow Cytometry - (0538)
AETNA-CPB-0618 — Brain Natriuretic Peptide Testing
Related Codes
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