Does H21.42 require prior authorization?

No, H21.42 does not require prior authorization (high confidence). Covered without prior authorization.

`H21.42`, Pupillary membranes, left 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 medical record must include the ordering provider's assessment related to the patient's complaint for that visit and documentation that supports medical necessity for SCODI.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
SCODI (CPT 92133) is covered when performed to evaluate or monitor optic nerve damage/optic neuropathy.
SCODI (CPT 92134) is covered for management of retinal diseases including wet age-related macular degeneration/choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema.
SCODI may be covered monthly (one scan per eye) for patients undergoing active intravitreal drug treatment for retinal disease.
SCODI may be covered monthly for other retinal/macular conditions undergoing rapid clinical change requiring aggressive therapy or frequent follow-up (examples: macular hole, traction retinal detachment).
Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.

CGS-J15-L34393, Ocular Photography - External

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CGS-J15-L34061, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J15

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J18-L34061, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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