J35.1 — Hypertrophy of tonsils
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
- 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.
Key Coverage Criteria
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
- 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.
7 Active Policies
A57473 — Billing and Coding: Allergy Testing
J05
L36402 — Allergy Testing
J05
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
AETNA-CPB-0004 — Obstructive Sleep Apnea in Adults
L34313 — Allergy Testing
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.