J02.0 — Streptococcal pharyngitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When performing pH-impedance testing for EoE evaluation or esophageal atresia, concurrent upper GI endoscopy and histology were used in studies ('All patients underwent upper GI endoscopy and pH-impedance monitoring' in the cited study).
- For MII-pH testing in refractory GERD, documentation of PPI dosing and timing when test is performed (on vs off PPI) — UpToDate guidance: administer high-dose acid-suppressive therapy for at least 1 week before combined MII-pH testing when evaluating refractory GERD; perform testing off PPIs when unclear if GERD is cause of symptoms ('we administer high-dose acid-suppressive therapy ... for at least 1 week before combined MII-pH testing' and 'we perform MII-pH testing off PPIs' when indicated).
- Probe synchronization and correct placement (studies noted measures to electronically synchronize probes when using two technologies concurrently).
Key Coverage Criteria
- ICD-10 codes listed as covered for MII-EM (when selection criteria are met): R07.9 (chest pain), R11.10–R11.14 (vomiting), R12 (heartburn), R13.10–R13.14 (dysphagia).
- CPT codes covered when selection criteria are met for esophageal pH monitoring: 91034 (nasal catheter pH), 91035 (mucosal attached telemetry pH / Bravo alternative) — (subject to the modality-specific selection criteria noted above).
- ICD-10 codes listed as covered for esophageal pH monitoring (when selection criteria are met): J02.0–J02.9 (acute pharyngitis), J04.0 (acute laryngitis), J31.2 (chronic pharyngitis), J37.0 (chronic laryngitis), J45.20–J45.50 (intermittent and persistent asthma, uncomplicated), K21.00–K21.9 (GERD), R05.1–R05.9 (cough), R07.9 (chest pain, unspecified).
- CPT codes covered when selection criteria are met for MII / MII-pH: 91037 (nasal catheter intraluminal impedance placement, recording, analysis, interpretation), 91038 (prolonged MII, >1 hour up to 24 hours).
- ICD-10 codes listed as covered for MII (when selection criteria are met): K21.00–K21.9 (GERD), R05.1–R05.9 (cough), R06.2 (wheezing), R10.0–R10.13 / R10.30–R10.9 (abdominal pain), R11.11 (vomiting without nausea), R12 (heartburn), R14.0–R14.3 (flatulence), R43.8 (disturbances of smell/taste), R62.50 (poor growth), R63.3 (feeding difficulties).
- CPT codes covered when selection criteria are met for MII-EM: 91010 (esophageal motility/manometry), 91037, 91038 (prolonged).
5 Active Policies
AETNA-CPB-0646 — Voice Therapy
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0667 — Esophageal and Airway pH Monitoring
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
Related Codes
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