Does H02.413 require prior authorization?

No, H02.413 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H02.413`, Mechanical ptosis of bilateral eyelids

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.
Documentation should include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures supporting the need for visual fields testing.
The diagnosis code(s) reported on the claim must best describe the patient's condition for which the visual fields testing was performed.
Refer to NCCI and OPPS requirements prior to billing Medicare to ensure coding compliance and to determine any bundling or packaging edits.

Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
Medically necessary upper eyelid blepharoptosis repair may be paid when performed concurrently with cosmetic blepharoplasty on the same eye during the same visit if medical necessity is documented.
Visual field impairment demonstrated by testing or clinical notes showing a 12–15 degree superior visual field loss or a 24%–30% superior visual field impairment constitutes medical necessity for blepharoptosis repair.
Near or distance visual impairment or documented difficulty reading attributable to upper eyelid drooping supports medical necessity for surgery.
Patient complaints or physical findings of interference with vision or visual field (for example difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue) support medical necessity.
Chronic eyelid dermatitis caused by redundant eyelid skin is an indication for blepharoplasty.

CGS-J15-L33944, Blepharoplasty

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L33944, Blepharoplasty

J18

CGS-J18-L34394, Visual Fields Testing

J18

A56908, Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

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