Does H04.531 require prior authorization?

No, H04.531 does not require prior authorization (high confidence). Covered without prior authorization.

`H04.531`, Neonatal obstruction of right nasolacrimal duct

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.
An interpretation and report specific to the photograph(s), including comparison to prior photographs when available, must be maintained in the medical record and available to the contractor upon request.
If additional photographs are taken to track changes, written documentation describing those changes must be maintained in the patient's medical record.

External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.
External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
Balloon dacryocystoplasty (balloon dacryoplasty) for the treatment of: a mucocele of the lacrimal sac.
Balloon dacryocystoplasty for the treatment of: chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction.
Balloon dacryocystoplasty for the treatment of: congenital nasolacrimal duct obstruction that can not be cured by probing (members should be over 1 year of age).

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34393, Ocular Photography - External

J18

AMBETTER-CP.VP.43, External Ocular Photography

AETNA-CPB-0420, Nasolacrimal Duct Obstruction: Treatments

A57068, Billing and Coding: Ocular Photography - External

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