Does D57.04 require prior authorization?

No, D57.04 does not require prior authorization (high confidence). Covered without prior authorization.

`D57.04`, Hb-SS disease with dactylitis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

For fundus photography, the medical record must document relevant medical history, physical examination, pertinent diagnostic test results, retention of the photographs, an interpretation/report, whether the pupil was dilated, and which drug was used; records must be legible and available to the carrier.
For extended ophthalmoscopy the record must include relevant history, physical exam, pertinent diagnostic results, retinal drawings meeting Appendix A specifications (separate detailed sketch 3-4 inches, labeled, colors preferred), and documentation of the method of examination and pupil dilation/drug; records must be legible and available.
For a diagnosis of glaucoma (ICD H40.001-H40.152) documentation must include a separate detailed optic nerve drawing with an interpretation that affects treatment, and documentation of cupping, disc rim, pallor, slope, and any surrounding pathology.

Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.
Conditions including tuberculosis of eye (A18.53, A18.54), diabetes mellitus with ophthalmic complications (E08.311-E08.359, E09.311-E09.359, E10.311-E10.359, E11.311-E11.359, E13.311-E13.359), ophthalmia nodosa (H16.241-H16.249), selected anterior segment disorders (H20.00-H21.1X1), and transient cerebral ischemic attacks with ocular involvement (G45.3) may require extended ophthalmoscopy and are covered.
Malignant and secondary neoplasms of the eye and adnexa (C69.20-C69.42, C79.89-C79.9) and benign neoplasms of the eye and adnexa (D31.20-D31.32) may require and are covered for extended ophthalmoscopy.
Other ocular conditions generally requiring monitoring may be covered for extended ophthalmoscopy when documentation supports medical necessity, subject to specified frequency limits.

CGS-J15-L34175, Ophthalmic Angiography (Fluorescein and Indocyanine Green)

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L38249, MolDX: Blood Product Molecular Antigen Typing

J15

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

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