Q76.9 — Congenital malformation of bony thorax, unspecified
ICD-10-CM
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
- Noninvasive positive pressure ventilation therapy (NPPV) with a home ventilatoris consideredmedically necessaryfor the following conditions (A, B,orC):
- The primary cause of respiratory failure is neuromuscular disease (for example, amyotrophic lateral sclerosis) or restrictive thoracic disease (for example, thoracic cage abnormalities) when either of the following criteria 1or2 are met:An arterial blood gas PaCO2level is greater than or equal to 45 mm Hg while awake and breathing the individual's usual FIO2;orThe individual has a maximum inspiratory pressure of less than or equal to 60 cm H2O.or
- An arterial blood gas PaCO2level is greater than or equal to 45 mm Hg while awake and breathing the individual's usual FIO2;or
- The individual has a maximum inspiratory pressure of less than or equal to 60 cm H2O.or
- Hypercapnic end-stage chronic obstructive pulmonary disease (COPD) when criteria 1or2 are met:Palliative use for individuals with advanced COPD and an active advance directive not to intubate;orPersistent hypercapnia with a PaCO2level of 53 mm Hg or greater on room air;or
- Palliative use for individuals with advanced COPD and an active advance directive not to intubate;or
2 Active Policies
AMBETTER-CP.MP.242 — Pulmonary Function Testing
ANTHEM-CG-DME-47 — CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure
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