Does E11.36 require prior authorization?

No, E11.36 does not require prior authorization (high confidence). Covered without prior authorization.

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`E11.36`, Type 2 diabetes mellitus with diabetic cataract

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical record must document the nature of visual impairment and specific decreased activities of daily living attributable to the cataract.
Document that other ocular diseases have been evaluated and ruled out as the primary cause of decreased visual function.
Document best corrected visual acuity (distance and/or near) and results of additional testing if used (consensual light testing or glare testing including line-change results).
Document expectation of significant visual improvement from the procedure and that the patient has been educated about risks, benefits, and alternatives to surgery (informed consent).

Key Coverage Criteria

Patient has a cataract causing impairment of visual function with decreased ability to perform activities of daily living (e.g., reading, watching television, driving, occupational/vocational tasks).
Best corrected visual acuity (distance or near) of 20/50 or worse documented in the medical record.
Consensual light testing that decreases visual acuity by two lines provides indication for cataract extraction when documented.
Glare testing that decreases visual acuity by two lines provides indication for cataract extraction when documented.
The patient states they can no longer function adequately with current visual function and this is documented in the record.
Other eye diseases (e.g., macular degeneration, diabetic retinopathy) have been ruled out as the primary cause of the decreased visual function.

20 Active Policies

CGS-J15-L33954, Cataract Extraction

J15

CGS-J15-L40199, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

J15

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

J15

CGS-J15-L34394, Visual Fields Testing

J15

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E11.36, Type 2 diabetes mellitus with diabetic cataract