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ICD-10-CM H04.569, Stenosis of unspecified lacrimal punctum | No Prior Auth

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`H04.569`, Stenosis of unspecified lacrimal punctum

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For clinical use as presented in the literature, documentation should include the imaging modality and device used, numerical values for the measured parameter(s) (e.g., ONSD in mm, RNFL/GCIPL thickness in µm, OCTA vessel density %), measurement technique and timing (e.g., relation to ROSC or symptom onset), and image quality metrics or notes on artifacts.
Accepted optic nerve and retinal imaging methods include the following: Confocal laser scanning ophthalmoscopy; Nerve fiber layer testing or analysis (confocal laser scanning tomography with polarimetry); Optical coherence tomography (OCT); Stereophotogrammetry.
In addition to annual screening that should begin after 5 years of use (or sooner if there are unusual risk factors), a baseline study of optic nerve and retinal imaging is considered medically necessary before initiation of chloroquine, hydroxychloroquine, or vigabatrin therapy.

Key Coverage Criteria

Age-related macular degeneration
Pseudotumor cerebri
B58.01 Toxoplasma chorioretinitis
C69.20 - C69.32 Malignant neoplasm of the retina and choroid
D18.09 Hemangioma of other sites [retina]
B50.0 - B54 Malaria

1 Active Policy

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

Related Codes

92134(1 policies)A28.1(1 policies)B39.4(1 policies)B50.0(1 policies)B54(1 policies)B58.01(1 policies)C69.20(1 policies)92133(1 policies)

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CPT codes 92133 and 92134 are 'covered if selection criteria are met' (the policy states 'CPT codes covered if selection criteria are met').

For drug-toxicity screening/monitoring (e.g., chloroquine/hydroxychloroquine/ethambutol/vigabatrin/etc.) documentation should include baseline imaging (prior to initiation) and records supporting timing of follow-up (annual screening beginning after 5 years of use, or sooner if unusual risk factors) as specified in the policy.

No explicit coverage-specific documentation requirements are stated in this document chunk.