Does H11.069 require prior authorization?

No, H11.069 does not require prior authorization (high confidence). Covered without prior authorization.

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`H11.069`, Recurrent pterygium of unspecified eye

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For allo-limbal transplants or allogeneic corneal epithelial stem cell transplantation: documentation of donor source (living-related, cadaver), HLA matching if applicable, and planned systemic immunosuppression regimen and monitoring.
For autologous ex-vivo expanded limbal epithelial transplantation: documentation of donor biopsy site, cell culture method and characteristics (e.g., percentage of p63-bright holoclone-forming stem cells) when available and pertinent to prognosis.
Pre-procedure clinical notes describing indication, prior failed therapies, risks/benefits discussed, and informed consent.
Post-operative follow-up documentation: epithelialization status, pain/symptom relief, visual acuity measurements, graft integrity, and any adverse events (e.g., infection, graft rejection, extrusion).

Key Coverage Criteria

Aniridia (hereditary)
Corneal limbal dermoid
Limbal stem cell transplantation for gelatinous drop-like corneal dystrophy
Neuropathic corneal pain
Tube erosion (double-layer amniotic membrane technique)
Management of ocular surface and orbital disorders (using ProKera/sutureless devices)

3 Active Policies

ANTHEM-CG-SURG-127, Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

AETNA-CPB-0293, Corneal Graft and Amniotic Membrane Transplantation, Corneal Stromal Lenticule Transplantation, Limbal Stem Cell Transplantation, or Sural Nerve Grafting for Ocular Indications

AETNA-CPB-0681, Corneal Pachymetry

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H11.069, Recurrent pterygium of unspecified eye