Benefit/program verification required

Verify that this policy applies to the member’s specific Capital BlueCross product and program prior to ordering or performing FeNO testing, because the policy is applicable only to certain programs and products and is subject to benefit variations.

• Confirm member eligibility and benefit limitations on date of service.
• Refer to product-specific guidance (e.g., FEP PPO: FEP medical policy manual).

FeNO coding and coverage note (CPT 95012)

Procedure code 95012 for FeNO testing is listed in the coding section as investigational and not covered; verify member benefits and any payer-specific memos before billing or ordering the test.

• Identification of a code in the coding section does not denote coverage; codes are subject to change.
• Confirm coverage status with member benefit information and prior authorization requirements per product terms.

Prior authorization and delegation — check current pathway

Check current prior authorization processes and delegated vendors before requesting authorization; some services and codes (for example, exhaled breath condensate/CPT 83987) have been delegated to Evicore and authorization pathways may have changed.

• When delegated, follow the payer’s delegated vendor (Evicore) prior authorization requirements for the affected codes.
• Review policy history and administrative updates for changes to authorization/delegation.

FeNO is adjunctive to clinical assessment

Use FeNO only as an adjunct to established clinical and laboratory assessments—FeNO measurements support but do not replace standard clinical evaluation and tests when diagnosing or managing asthma.

• FeNO measurements are described as an adjunct to established clinical and laboratory assessments in asthma.
• Continue routine monitoring with spirometry/FEV1 and clinical assessment rather than relying on FeNO alone.

Testing frequency and therapy monitoring guidance

Follow guidance on repeat testing and corticosteroid tapering: consider repeating blood eosinophils and FeNO up to three times before assuming non–type 2 inflammation, and use FeNO-supported monitoring when tapering oral corticosteroids after response to type 2 targeted therapy.

• Repeat blood eosinophils and FeNO up to 3 times (e.g., when asthma worsens, before giving OCS, or at least 1–2 weeks after a course of OCS).
• When patient responds to type 2 targeted therapy, consider gradual OCS tapering supported by monitoring symptoms and FeNO.

No FeNO-specific step therapy requirements specified

No step therapy requirements are specified in the policy sections referenced; do not assume any FeNO-specific step therapy pathway is required by this policy.

• Documented policy sections do not list step therapy requirements for FeNO testing or related therapies.

Use FDA‑cleared FeNO devices (FDA product code MXA)

When performing FeNO testing, use FDA–cleared devices and heed device-specific indications; devices for FeNO measurement are cleared under FDA product code MXA and are intended as adjuncts to clinical assessment with age/cooperation limitations noted by device labeling.

• Devices cleared for FeNO measurement are listed with FDA product code MXA.
• Device labeling notes age and cooperation limitations (e.g., some devices not for infants; some suitable for children 7 years and older) and that FeNO is to be used as an adjunct to clinical assessment.

Documentation and benefit verification required

Provide documentation and verify benefits at time of service: coverage and payment depend on the member’s benefit program, eligibility on the date of service, and whether the service is deemed medically necessary per contract terms.

• Supply documentation that supports medical necessity consistent with current policy wording.
• Confirm member eligibility and benefit limitations before submitting claims; identification of a code does not imply coverage.

Match documentation to current policy and coding

Ensure submitted clinical documentation matches the currently effective policy and coding because policy history and administrative updates have changed coding and criteria over time; provide records that reflect the current policy requirements.

• Policy history documents multiple revisions and administrative updates; supply documentation consistent with the effective policy.
• Removed criteria (e.g., exhaled breath condensate/CPT 83987) have been delegated—do not submit documentation for removed criteria as if current.

Investigational status — denial risk for diagnostic/management use

Testing of FeNO for diagnosis or management of asthma, eosinophilic asthma, and other respiratory disorders is considered investigational; claims for these indications may be denied on that basis.

• Measurement of exhaled nitric oxide is considered investigational for asthma, eosinophilic asthma, and other respiratory disorders due to insufficient evidence of net health outcome benefit.
• Anticipate denials when services are inconsistent with the policy’s investigational determination.

Investigational / not covered: CPT 95012

Procedure code 95012 is listed as investigational and therefore not covered; billing the code may result in claim denial under this policy.

• 95012 is explicitly listed in the policy’s 'Investigational; therefore, not covered' coding list.
• Verify coverage and consider alternative coding/documentation if applicable.

Policy history: 02/27/2025 major review — stance changed to investigational

Note the 02/27/2025 Major Review that changed the policy to investigational and ensure documentation and claims reflect the current investigational stance rather than prior medically necessary criteria.

• Policy history: 02/27/2025 Major Review — measurement of exhaled nitric oxide is now investigational.
• Do not rely on earlier versions that listed medically necessary criteria; supply documentation consistent with the current policy effective dates.