Does T86.812 require prior authorization?

No, T86.812 does not require prior authorization (high confidence). Code is covered without prior authorization.

`T86.812` — Lung transplant infection

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for the HCPCS codes specified under Final Rule 1713; claims lacking these per the LCD-related Standard Documentation Requirements Article will be denied.
For add-on ensifentrine (J7601) therapy, the treating practitioner must document continuation of dual or triple maintenance therapy and either (a) history of continued COPD exacerbations within 12 months evidenced by hospitalization, ER visit, or new prescription for systemic glucocorticoids or antibiotics, or (b) during one exacerbation a combination of at least three clinical parameters (dyspnea VAS >5, respiratory rate >24 bpm, heart rate >95 bpm, oxygen saturation decline >=3% from baseline, or CRP >10 mg/L); also document persistent COPD-related dyspnea by persistent breathlessness or exercise limitation.
A diagnosis code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.

Nebulizers are covered under the Durable Medical Equipment (DME) benefit when the reasonable and necessary (R&N) requirements in the related Local Coverage Determination (LCD) are met.
Unfilled nebulizers (HCPCS A7007, A7017, E0585) filled with water or saline (A4217 or A7018) by the beneficiary or caregiver are an acceptable covered alternative.
Add-on ensifentrine (J7601) therapy to dual LABA+LAMA maintenance therapy or LABA+LAMA+ICS triple maintenance therapy for COPD is covered when the treating practitioner documents continuation of maintenance therapy and the required exacerbation or dyspnea criteria in the medical record.
Immunosuppressive drugs are covered when prescribed following a covered organ transplant of kidney, heart, liver, bone marrow/stem cell, lung, or combined heart-lung.
Immunosuppressive drugs are covered after a whole-organ pancreas transplant that was performed concurrent with or subsequent to a kidney transplant for diabetic nephropathy when the transplant was performed on or after 1999-07-01.
Immunosuppressive drugs are covered after an intestinal transplant performed on or after 2001-04-01.

L37205 — Chemotherapy Drugs and their Adjuncts

J05

A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

J05

L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

Ask Verity about documentation requirements, denial risks, or coverage in your state.