Does H11.001 require prior authorization?

No, H11.001 does not require prior authorization (high confidence). Covered without prior authorization.

`H11.001`, Unspecified pterygium of 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.
For diagnostic tests, report the test result on the claim if known; if the result is not known at time of billing, report the symptoms that prompted the test.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Computerized corneal topography is billable when performed as a diagnostic test for corneal conditions and the claim includes a diagnosis code that best describes the patient's condition for which the service was performed.
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.
Aniridia (hereditary)

CGS-J15-L34008, Computerized Corneal Topography

J15

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34008, Computerized Corneal Topography

J18

CGS-J18-L34393, Ocular Photography - External

J18

A56537

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