Measurement of Exhaled Nitric Oxide

Policy ID: G-43-006

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: July 05, 2024

Revision Effective Date: September 01, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Nitric oxide (NO) is an endogenous messenger and inflammatory mediator that is widespread in the human body. While the role of NO in asthma pathogenesis is still under investigation, individuals with eosinophilic asthma have been found to have high levels of fractional exhaled nitric oxide (FeNO), which decreases with treatment with corticosteroids.

In the gas phase, NO is fairly stable, permitting its measurement in exhaled air. FeNO is typically measured during single breath exhalations. First, the subject inspires NO-free air via a mouthpiece until total lung capacity is achieved, followed immediately by exhalation through the mouthpiece into the measuring device.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Measurement of exhaled NO (i.e., FeNO) may be considered medically necessary in the management of individuals with an established diagnosis of eosinophilic asthma.

Measurement of exhaled NO (i.e., FeNO) not meeting the criteria as indicated in this policy is/are considered not medically necessary.

Procedure Code

95012

Diagnosis Codes

*Note: Two (2) diagnosis codes are required - one (1) code from the asthma code grid below and one (1) eosinophilic asthma diagnosis code (J82.83).

Covered Diagnosis Code for Asthma*: 95012

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

**Covered Diagnosis Code for Eosinophilic Asthma*: 95012**

J82.83

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-20 Annual Review

Added Procedure codes 11920, 11921, 19350, and 19499
Per ND review outside of IMPC 4-19-2021 Removed procedure codes 11920; 11921; 19350 and 19499

Internal Medical Policy Committee 11-23-2021 Annual Review- no changes in criteria

Internal Medical Policy Committee 01-20-2022 Updated Diagnosis codes for 95012, covered diagnosis codes.

Internal Medical Policy Committee 07-21-2022 Revision-

Updated with clarifying language and Coding updates for Diagnosis Codes
Added Diagnosis codes J45.901; J45.902; J45.909

Internal Medical Policy Committee 1-26-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 1-16-2024 Annual review-no changes in criteria

Internal Medical Policy Committee 7-16-2024 Revision - Effective September 02, 2024

Updated wording in Diagnosis section; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.