Medicare Advantage

Medical Policy

Notification

Pulmonary Function Tests

Notification Issue Date: 03/07/2025

Effective 04/07/2025, this policy will be archived because this service is considered standard of care, as determined by a review of available published literature and Company policy.

Medical Policy Bulletin

Title:

Pulmonary Function Tests

Policy #:

MA07.007o

Policy

MEDICALLY NECESSARY

SPIROMETRY
Diagnostic

Spirometry used for diagnostic purposes is considered medically necessary and, therefore, covered when used for any of the following:

To evaluate signs, symptoms, or abnormal laboratory tests or radiology studies:
- Signs: unexplained decreased breath sounds, overinflation, cyanosis, chest deformity, wheezing, or unexplained adventitious sounds
- Symptoms: unexplained dyspnea, wheezing, orthopnea, cough, or phlegm production
- Abnormal laboratory tests or radiology studies: (e.g., hypoxemia, hypercapnia, polycythemia, or abnormal chest radiographs)
To measure the effect of systemic disease on pulmonary function (e.g., neuromuscular disease and connective tissue disease)
To assess an individual's preoperative risk
To assess prognosis (e.g., lung transplant, etc.)

Monitoring

Spirometry used for monitoring purposes is considered medically necessary and, therefore, covered when used for either of the following:

To assess therapeutic intervention for any of the following:
- Bronchodilator therapy (see below)
- Steroid treatment for asthma, interstitial lung disease, etc.
- Other: (e.g., the use of intravenous antibiotics in the treatment of cystic fibrosis, the management of idiopathic pulmonary fibrosis and chest wall deformities)
To monitor for adverse reactions to drugs with known pulmonary toxicity

Spirometry Following Bronchodilator Therapy

Post-bronchodilator spirometry is used to rule out a reversible component to an individual's bronchospasm and to determine if the individual is a candidate for bronchodilator therapy. Therefore, spirometry used for bronchodilator responsiveness (94060) will be considered medically necessary and, therefore, covered for any of the following indications:

Individual has signs and/or symptoms consistent with a bronchospasm.
Spirometry performed, without the use of a bronchodilator, is abnormal.
Reversibility of bronchospasm in response to bronchodilator therapy has not yet been demonstrated.

If reversibility of a bronchospasm (bronchodilator responsiveness) has already been either ruled out or demonstrated, a repeat pre- and post-bronchodilator spirometry to evaluate responsiveness (94060) will be considered medically necessary and, therefore, covered when there is a significant clinical change in the individual's functional respiratory status necessitating an adjustment or augmentation of bronchoactive medications.

INDIRECT CALORIMETRY CALCULATIONS
Exhaled air analysis (94690) is used in calorimetry calculation. Indirect calorimetry is used to measure the resting energy expenditure of individuals with morbid obesity to establish their minimum energy requirements.

Exhaled air analysis, when billed with a diagnosis of morbid obesity (E66.01), will be considered medically necessary and, therefore, covered once every 2 years.

LUNG VOLUMES AND CAPACITIES
The measurement of absolute lung volumes or capacities (i.e., total lung capacity [TLC], residual volume [RV], and functional residual capacity [FRC]) is considered medically necessary and, therefore, covered for any of the following:

When the vital capacity (VC) is reduced
To distinguish restrictive disease from chronic obstructive pulmonary disease (COPD)
For the evaluation of bullous diseases and to explain the data from other lung functions
For the assessment of therapeutic interventions, such as a lobectomy and chemotherapy

LUNG DIFFUSION CAPACITY (DLCO)
Diffusion capacity (DLCO) measurement is considered medically necessary and, therefore, covered when spirometry and lung volume studies reveal restrictive disease.

LUNG COMPLIANCE
Lung compliance studies are considered medically necessary and, therefore, covered, when all other pulmonary function tests (PFTs) give equivocal results or the results require confirmation by additional data.

Physician review of a patient-recorded spirometry (94014, 94015 and 94016) is considered medically necessary and, therefore covered when provided consistent with the above-listed criteria.

NOT MEDICALLY NECESSARY

All other uses for pulmonary function tests, including for screening purposes, are considered not medically necessary and, therefore, not covered.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Vital capacity, total (separate procedure) (94150) is always considered to be included in the reimbursement for other services and, therefore, is not eligible for separate reimbursement, whether billed alone or in conjunction with other services.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare’s coverage determination for pulmonary function tests. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, pulmonary function tests are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

Description

Pulmonary function tests (PFTs) are a group of tests that measure how well the lungs take in and release air and how well the lungs move gases such as oxygen from the atmosphere into the body's circulation.

SPIROMETRY

Spirometry, the most commonly used type of PFTs, is the measurement of airflow via an instrument called a spirometer. By measuring how much air is exhaled, and how quickly, spirometry can evaluate a broad range of lung diseases.

The evaluation of lung function can be used to determine any of the following indications:

Presence of lung disease or abnormality of lung function
Extent of abnormalities and the potential causative disease process
Extent of disability due to abnormal lung function
Progression of the disease
Type of disease or lesion
Response to a course of therapy in the treatment of the particular condition
Presence of lung disease or abnormality of lung function secondary to toxicity of medication

Post-bronchodilator spirometry is used to rule out a reversible component to an individual's bronchospasm and determine if the individual is a candidate for bronchodilator therapy.

INDIRECT CALORIMETRY CALCULATIONS

Indirect calorimetry calculations are used to calculate an individual's energy expenditure.

LUNG VOLUMES AND CAPACITIES

Lung volumes (i.e., total lung capacity [TLC], residual volume [RV], and functional residual capacity [FRC]) are used when vital capacity is reduced. The test measures how much air is present in the lungs when a deep breath is taken and how much air remains in the lungs after breathing out fully. Lung volume measurement can help diagnose pulmonary fibrosis or a stiff or weak chest wall.

LUNG DIFFUSION CAPACITY

Diffusion capacity (DLCO) measurement is used to help distinguish between an intrinsic pulmonary process, such as interstitial lung disease and emphysema, and an extrapulmonary process, such as chest wall and neuromuscular disorders. This test measures how well oxygen passes from the lungs to the bloodstream.

LUNG COMPLIANCE

Lung compliance measures the elastic recoil or stiffness of the lungs. It is more invasive than other PFTs because the individual is required to swallow an esophageal balloon.

References

Novitas Solutions, Inc. Local Coverage Article (LCA) A57320 - Billing and Coding: Pulmonary Function Testing. [Novitas Solutions website]. Original 10/01/2019. (Revised 10/01/2022). Available at: Article - Billing and Coding: Pulmonary Function Testing (A57320) (cms.gov). Accessed February 15, 2023.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35360 - Pulmonary Function Testing. [Novitas Solutions website]. Original 10/01/2015. (Revised 07/01/2020). Available at: Local Coverage Determination for Pulmonary Function Testing (L35360) (cms.gov). Accessed February 15, 2023.

Ranu H, Wilde M, Madden B. Pulmonary function tests. Ulster Med J. 2011;80(2):84-90. Abstract Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229853/. Accessed February 15, 2023.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

94010, 94011, 94012, 94013, 94014, 94015, 94016, 94060, 94070, 94200, 94375, 94450, 94680, 94681, 94690, 94726, 94727, 94728, 94729

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

94150

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Attachment A: Pulmonary Function Tests
Description: Diagnosis Codes (ICD-10)

Policy History

Revisions From MA07.007o:

10/01/2024

This policy has been identified for the ICD-10 code update, effective 10/01/2024.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 code has been termed and deleted from Attachment A of this policy:
C88.0 Waldenstrom macroglobulinemia

The following ICD-10 codes have been added to Attachment A of this policy:
C88.00 Waldenstrom macroglobulinemia not having achieved remission
I26.03 Cement embolism of pulmonary artery with acute cor pulmonale
I26.04 Fat embolism of pulmonary artery with acute cor pulmonale
I26.95 Cement embolism of pulmonary artery without acute cor pulmonale
I26.96 Fat embolism of pulmonary artery without acute cor pulmonale

The following ICD-10 codes have been revised in Attachment A of this policy:
Changed From: I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale

Changed To: I26.93 Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale

Changed From: I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale

Changed To: I26.94 Multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale

Revisions From MA07.007n:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
10/01/2023	This policy has been identified for the ICD-10 code update, effective 10/01/2023. Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. The following ICD-10 codes have been added to Attachment A of this policy: J44.89 Other specified chronic obstructive pulmonary disease T56.821A Toxic effect of gadolinium, accidental (unintentional), initial encounter

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

10/01/2023

This policy has been identified for the ICD-10 code update, effective 10/01/2023.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 codes have been added to Attachment A of this policy:
J44.89 Other specified chronic obstructive pulmonary disease
T56.821A Toxic effect of gadolinium, accidental (unintentional), initial encounter

Revisions From MA07.007m:

03/22/2023

The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Function Tests.

10/01/2022

This policy has been identified for the ICD-10 code update, effective 10/01/2022.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 code has been revised in Attachment A of this policy:
C84.42
FROM: Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes
TO: Peripheral T-cell lymphoma, not elsewhere classified, intrathoracic lymph nodes

The following ICD-10 codes have been added to Attachment A of this policy:
G71.031 Autosomal dominant limb girdle muscular dystrophy
G71.032 Autosomal recessive limb girdle muscular dystrophy due to calpain-3 dysfunction
G71.033 Limb girdle muscular dystrophy due to dysferlin dysfunction
G71.0340 Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified
G71.0341 Limb girdle muscular dystrophy due to alpha sarcoglycan dysfunction
G71.0342 Limb girdle muscular dystrophy due to beta sarcoglycan dysfunction
G71.0349 Limb girdle muscular dystrophy due to other sarcoglycan dysfunction
G71.035 Limb girdle muscular dystrophy due to anoctamin-5 dysfunction
G71.038 Other limb girdle muscular dystrophy
G71.039 Limb girdle muscular dystrophy, unspecified
J95.87 Transfusion-associated dyspnea (TAD)

Revisions From MA07.007l:

05/20/2021

The version of this policy is retro-effective to 05/20/2021.

The following ICD-10 codes was added to Attachment A of this policy:

J12.82 Pneumonia due to coronavirus disease 2019

Revisions From MA07.007k:

10/01/2021

This policy has been identified for the ICD-10 code update, effective 10/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 codes have been deleted from Attachment A of this policy:
M31.1 Thrombotic microangiopathy
R05 Cough

The following ICD-10 codes haves been revised in Attachment A of this policy:
M35.00
FROM: Sicca syndrome, unspecified
TO: Sjogren syndrome, unspecified

M35.02
FROM: Sicca syndrome with lung involvement
TO: Sjogren syndrome with lung involvement

The following ICD-10 codes have been added to Attachment A of this policy:
M31.10 Thrombotic microangiopathy, unspecified
M31.11 Hematopoietic stem cell transplantation-associated thrombotic microangiopathy [HSCT-TMA]
M31.19 Other thrombotic microangiopathy
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough syncope
R05.8 Other specified cough
R05.9 Cough, unspecified

Revisions From MA07.007j:

01/02/2021

The version of this policy was published on 04/26/2021 with a retroactive effective date of 01/02/2021.

The Company’s coverage position has changed from Not Covered to Medically Necessary regarding physician review of patient-recorded spirometry:

Physician review of a patient-recorded spirometry (94014, 94015 and 94016) is considered medically necessary and, therefore covered when provided consistent with policy criteria.

The following ICD-10 code was deleted from Attachment A of this policy:

M35.8 Other specified systemic involvement of connective tissue

The following ICD-10 codes was added to Attachment A of this policy:

M35.89 Other specified systemic involvement of connective tissue

Revisions From MA07.007i:

01/01/2021

This policy has been identified for the CPT code update, effective 01/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following CPT codes have been termed and removed from this policy:

94250, 94400, 94750, 94770

Revisions From MA07.007h:

10/01/2020

This policy has been identified for the ICD-10 CM code update, effective 10/01/2020.

The following ICD-10 codes have been added to Attachment A in this policy:

J82.81 Chronic eosinophilic pneumonia

J82.82 Acute eosinophilic pneumonia

J82.83 Eosinophilic asthma

J82.89 Other pulmonary eosinophilia, not elsewhere classified

J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere

J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere

The following ICD-10 codes have been deleted in Attachment A in this policy:

J82 Pulmonary eosinophilia, not elsewhere classified

J84.17 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere

Revisions From MA07.007g:

03/11/2020	The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Function Tests.
01/01/2020	This policy has been identified for the CPT code update, effective 01/01/2020. The following CPT code narrative has been revised in this policy: 94728

Revisions From MA07.007f:

10/01/2019

This policy has been identified for the ICD-10 CM code update, effective 10/01/2019.

The following ICD-10 codes have been added to Attachment A in this policy:

I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale

I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale

The following ICD-10 narratives have been revised in Attachment A in this policy:

Changed from:
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

Changed to:
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection

Revisions From MA07.007e:

02/13/2019

The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Function Tests.

10/01/2018

This policy has been identified for the ICD-10 code update, effective 10/01/2018.

The following ICD-10 CM code has been deleted from Att A of this policy:

G71.0 Muscular dystrophy

The following ICD-10 CM codes have been added to Att A of this policy:

G71.00 Muscular dystrophy, unspecified
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies

Revisions From MA07.007d:

03/23/2018

This version of the policy will become effective 03/23/2018. The intent of this policy remains unchanged; however, the following codes have been added to this policy.

Coding:
The following ICD-10 codes have been added to Attachment A in this policy:

G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.22 Progressive bulbar palsy
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified

Revisions From MA07.007c:

10/01/2017

This version of the policy will become effective 10/01/2017.
The following ICD-10 codes have been added to Attachment A in this policy.

I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.83 Eisenmenger's syndrome
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
R06.03 Acute respiratory distress

The following ICD-10 CM code has been deleted from Attachment A in this policy:
I27.2

The following ICD-10 narratives have been revised in Attachment A in this policy:

I50.1
FROM: Left ventricular failure
TO: Left ventricular failure, unspecified

M33.01
FROM: Juvenile dermatopolymyositis with respiratory involvement
TO: Juvenile dermatomyositis with respiratory involvement

M33.11
FROM: Other dermatopolymyositis with respiratory involvement
TO: Other dermatomyositis with respiratory involvement

Revisions From MA07.007b:

07/14/2017

The following changes have been made to Attachment A

CPT CODES 94010, 94060, 94200, 94250, 94375, 94400, 94450, 94680, 94681, 94690, 94726, 94727, 94728, 94729, 94750 AND 94770 ARE MEDICALLY NECESSARY WHEN REPORTED WITH THE DIAGNOSIS CODES LISTED IN ATTACHMENT A.

The following diagnosis have been REMOVED:

B40.9 Blastomycosis, unspecified
J98.51 Mediastinitis
Q33.2 Sequestration of lung

The following diagnosis codes have been ADDED

T53.4X2A Toxic effect of dichloromethane, intentional self-harm, initial encounter
T53.4X2D Toxic effect of dichloromethane, intentional self-harm, subsequent encounter
T53.4X2S Toxic effect of dichloromethane, intentional self-harm, sequela
T53.4X3A Toxic effect of dichloromethane, assault, initial encounter
T53.4X3D Toxic effect of dichloromethane, assault, subsequent encounter
T53.4X3S Toxic effect of dichloromethane, assault, sequela
T53.4X4A Toxic effect of dichloromethane, undetermined, initial encounter
T53.4X4D Toxic effect of dichloromethane, undetermined, subsequent encounter
T53.4X4S Toxic effect of dichloromethane, undetermined, sequela

Revisions From MA07.007a:

10/01/2016

This version of the policy will become effective 10/01/2016.

In accordance with Medicare, the following changes were incorporated:

The following ICD-10 CM codes have been added into this policy under the following sections:

CPT CODES 94010, 94060, 94200, 94250, 94375, 94400, 94450, 94680, 94681, 94690, 94726, 94727, 94728, 94729, 94750 AND 94770 ARE MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

A15.7, B38.1, B46.0, B46.4, B47.1, B58.3, B59, B67.1, B77.81, B90.9, B95.3, B96.0, C46.50, C46.51, C46.52, C7A.090, C7A.091, C78.1, C78.2, C78.39, C81.92, C82.02, C82.12, C82.22, C82.32, C82.42, C82.52, C82.62, C82.82, C82.92, C83.02, C83.12, C83.32, C83.52, C83.82, C83.92, C84.02, C84.12, C84.42, C84.62, C84.72, C84.A2, C84.Z2, C85.12, C85.22, C85.82, C85.92, C88.0, D14.2, D15.0, D38.2, D38.3, D38.4, D38.5, E66.2, G65.0, G82.50, G82.51, G82.52, G82.53, G82.54, I34.0, I34.2, I35.0, I35.1, J41.8, J68.0, J68.1, J68.2, J68.3, J68.4 J68.8, J68.9, J69.0, J69.1, J69.8, J80, J81.0, J81.1, J82, J84.01, J84.02, J84.03, J85.0, J85.1, J85.2, J85.3, J86.0, J95.02, J95.1, J95.2, J95.3, J95.4, J95.5, J98.2, J98.3, J98.51, J98.59, M06.1, M06.39, M08.1, M30.0, M30.1, M31.1, M31.2, M31.30, M31.31, M31.8, M31.9, M32.13, M33.01 M33.11, M33.21 M33.91, M34.9 M35.00, M35.02, M35.1, M35.8, M36.0, M40.292, M40.293, M40.294, M40.295, M40.30, M40.35, M40.45, M41.34,M41.35, M45.0, M45.2, M45.3, M45.4, M45.5, Q22.1, Q22.2, Q22.3, Q25.71, Q25.72, Q25.79, Q32.0, Q32.1, Q32.2, Q32.3, Q32.4, Q33.0, Q33.1, Q33.2 Q33.3, Q33.4, Q33.5, Q33.6, Q33.8, Q33.9, Q34.0, Q34.1, Q34.8, Q67.8, Q76.412, Q76.413, Q76.414, Q76.415, Q76.8, Q76.9, R94.2, T50.0X1A, T50.0X1D, T50.0X1S T50.0X2A, T50.0X2D, T50.0X2S T50.0X3A T50.0X3D T50.0X3S T50.0X4A T50.0X4D T50.0X4S T50.0X5A T50.0X5D T50. T50.1X1A T50.1X1D T50.1X1S T50.1X2A T50.1X2D T50.1X2S T50.1X3A T50.1X3D T50.1X3S T50.1X4A T50.1X4D T50.1X4S T50.1X5A T50.1X5D T50.1X5S T50.2X1A T50.2X1D T50.2X1S T50.2X2A T50.2X2D T50.2X2S T50.2X3A T50.2X3D T50.2X3S T50.2X4A T50.2X4D T50.2X4S T50.2X5A T50.2X5D T50.2X5S T50.3X1A T50.3X1D T50.3X1S T50.3X2A T50.3X2D T50.3X2S T50.3X3A T50.3X3D T50.3X3S T50.3X4A T50.3X4D T50.3X4S T50.3X5A T50.3X5D T50.3X5S T53.0X1A T53.0X1D T53.0X1S T53.0X2A T53.0X2D T53.0X2S T53.0X3A T53.0X3D T53.0X3S T53.0X4A T53.0X4D T53.0X4S T53.1X1A T53.1X1D T53.1X1S T53.1X2A T53.1X2D T53.1X2S T53.1X3A, T53.1X3D T53.1X3S T53.1X4A T53.1X4D T53.1X4S T53.2X1A T53.2X1D T53.2X1S T53.2X2A T53.2X2D T53.2X2S T53.2X3A T53.2X3D T53.2X3S T53.2X4A T53.2X4D T53.2X4S T53.3X1A T53.3X1D T53.3X1S T53.3X2A T53.3X2D T53.3X2S T53.3X3A T53.3X3D T53.3X3S T53.3X4A T53.3X4D T53.3X4S T53.4X1A T53.4X1D T53.4X1S T53.6X1A T53.6X1D T53.6X1S T53.6X2A T53.6X2D T53.6X2S T53.6X3A T53.6X3D T53.6X3S T53.6X4A T53.6X4D T53.6X4S T53.7X1A T53.7X1D T53.7X1S T53.7X2A T53.7X2D T53.7X2S T53.7X3A T53.7X3D T53.7X3S T53.7X4A T53.7X4D T53.7X4S T58.01XA T58.01XD T58.01XS T58.02XA T58.02XD T58.02XS T58.03XA T58.03XD T58.03XS T58.04XA T58.04XD T58.04XS T58.11XA T58.11XD T58.11XS T58.12XA T58.12XD T58.12XS T58.13XA T58.13XD T58.13XS T58.14XA T58.14XD T58.14XS T58.2X1A T58.2X1D T58.2X1S T58.2X2A, T58.2X2D T58.2X2S T58.2X3A T58.2X3D T58.2X3S T58.2X4A T58.2X4D T58.2X4S Z79.51

CPT CODE 94070 IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:
J44.0 J44.1 J45.21 J45.31 J45.41 R06.1 R06.2

The following ICD-10 CM codes have been deleted from this policy:

B40.3 B40.81 B40.9 B42.1 B42.81 B42.82 B42.9 B45.1, B45.2 B45.3 B45.9 D86.81 D86.83 D86.84 D86.86 E71.39 E71.40 E71.41 E71.42 E71.43 E71.440 E71.448 E80.3 E84.11 E84.9 G47.00 G47.10 G47.20 G47.30 G47.8 G47.9 J84.841 J84.842 J84.843 J84.848 M32.10 M32.11 M32.19 M32.8 M32.9 M40.00 M40.202 M40.203 M40.204 M40.205 M40.209 M41.116 M41.117 M41.119 M41.126 M41.127 M41.129 M41.20 M41.26 M41.27 Q76.426 Q76.427 Q76.428 Q76.429 R06.81 R06.83 T80.0XXA T80.0XXD T80.0XXS T81.718A T81.718D T81.718S T81.72XA T81.72XD T81.72XS T81.82XA T81.82XD T81.82XS T88.6XXA T88.6XXD T88.6XXS T88.7XXA T88.7XXD T88.7XXS Z79.02

In accordance with the ICD-10, 10/01/2016 Code update.

The following ICD-10 codes we revised in this policy

FROM: C81.12 Nodular sclerosis classical Hodgkin lymphoma, intrathoracic lymph nodes
TO: C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes

FROM: C81.22 Mixed cellularity classical Hodgkin lymphoma, intrathoracic lymph nodes
TO: C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes

FROM: C81.32 Lymphocyte depleted classical Hodgkin lymphoma, intrathoracic lymph nodes
TO: C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes

FROM: C81.42 Lymphocyte-rich classical Hodgkin lymphoma, intrathoracic lymph nodes
TO: C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes

FROM: C81.72 Other classical Hodgkin lymphoma, intrathoracic lymph nodes
TO: C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes

Revisions From MA07.007:

10/13/2015

This new policy has been developed to communicate the Medicare Advantage coverage criteria for pulmonary function tests.

Version Effective Date:

04/07/2025

Version Issued Date:

10/01/2024

Version Reissued Date:

N/A