P22.1 — Transient tachypnea of newborn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Physician order / prescription documenting the diagnosis and medical necessity for home pulse oximetry or capnography (e.g., chronic lung disease, severe cardiopulmonary disease, neuromuscular disease involving respiratory muscles, ventilator dependence, CCHS, interstage Norwood monitoring).
- Clinical documentation that explains the intended use: to determine appropriate oxygen liter flow for ambulation/exercise/sleep; to monitor a home ventilator; to support physician-directed adjustment of home oxygen (short-term one month); to document weaning from home oxygen; or for interstage monitoring after Norwood procedure.
- For capnography coverage, documentation of diagnosis of congenital central alveolar hypoventilation syndrome (ICD-10 G47.35) and clinical rationale for PETCO2 monitoring.
Key Coverage Criteria
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): I20.1 - I20.9 (Angina pectoris)
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): I27.0 - I27.9 (Other pulmonary heart diseases)
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): I50.20 - I50.9 (Congestive heart failure)
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): I73.9 (Peripheral vascular disease, unspecified)
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): J43.0 - J43.9 (Emphysema)
- ICD-10 covered diagnoses (pulse oximetry) when selection criteria are met (not all-inclusive): J44.9 (Chronic obstructive pulmonary disease, unspecified)
1 Active Policy
AETNA-CPB-0339 — Pulse Oximetry and Capnography for Home Use
Related Codes
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