Does H05.261 require prior authorization?

No, H05.261 does not require prior authorization (high confidence). Covered without prior authorization.

`H05.261`, Pulsating exophthalmos, right eye

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.
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.
Taped and un-taped visual field testing count as one unit of service for MUE (medically unlikely edits) purposes.

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34393, Ocular Photography - External

J18

CGS-J18-L34394, Visual Fields Testing

J18

A57483, Billing and Coding: Visual Fields

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