Does H05.20 require prior authorization?

No, H05.20 does not require prior authorization (high confidence). Covered without prior authorization.

`H05.20`, Unspecified exophthalmos

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
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.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
If the service requires a referring/ordering physician, include the ordering/referring physician’s name and NPI on the claim.
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.

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

CGS-J18-L34393, Ocular Photography - External

J18

A57483, Billing and Coding: Visual Fields

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