Does H04.129 require prior authorization?

No, H04.129 does not require prior authorization (high confidence). Covered without prior authorization.

`H04.129`, Dry eye syndrome of unspecified lacrimal gland

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation that the patient's diagnosis meets one of the covered indications (e.g., chronic neck pain or chronic headache with minimum 12 weeks duration where applicable).
Documentation of duration of symptoms when chronicity is required (policy explicitly requires minimum 12 weeks duration for chronic neck pain and chronic headache).
Documentation of clinical response: if no clinical benefit after four weeks of acupuncture, the treatment plan should be reevaluated; further treatment is not medically necessary if the member does not demonstrate meaningful improvement in symptoms.
Provider credentialing/license documentation showing the acupuncture is administered by a health care provider practicing within the scope of his/her license (and, where applicable by specific plans, documentation that provider is a legally qualified physician practicing within scope of license).

ANTHEM-CG-SURG-94, Keratoprosthesis

AETNA-CPB-0029, Thermography

AETNA-CPB-0135, Acupuncture and Dry Needling

AETNA-CPB-0344, Optic Nerve and Retinal Imaging Methods

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