Does H21.359 require prior authorization?

No, H21.359 does not require prior authorization (high confidence). Covered without prior authorization.

`H21.359`, Exudative cyst of pars plana, unspecified 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.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
Posterior segment OCT is reasonable and necessary to diagnose and manage retinal and neuro-ophthalmic diseases involving the optic nerve, subretinal and intraretinal abnormalities, vitreoretinal relationships, or retinal nerve fiber layer changes.
Posterior segment OCT is reasonable and necessary to diagnose early glaucoma and to monitor glaucoma treatment.
Posterior segment OCT may be used to differentiate causes of optic nerve disorders when the diagnosis is uncertain.
Posterior segment OCT may be used to diagnose or manage the patient when visual field results are insufficient or reliable visual field testing cannot be performed due to visual, physical, mental, or age-related constraints.

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A56537, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

FIRST_COAST-L33766, Visual Field Examination

A57637, Billing and Coding: Visual Field Examination

Ask Backwork about documentation requirements, denial risks, or coverage in your state.