Does H21.43 require prior authorization?

No, H21.43 does not require prior authorization (high confidence). Covered without prior authorization.

`H21.43`, Pupillary membranes, bilateral

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Document general ophthalmoscopy and biomicroscopy findings in the medical record even when these services are included in extended ophthalmoscopy and not separately billed.
For extended ophthalmoscopy, include a drawing or equivalent documentation that demonstrates the extended nature of the exam to support separate payment.
Orders for CPT 92227 and CPT 92228 must be from the treating physician or other treating practitioner acting within the scope of license and Medicare requirements and this order must be documented in the record.
When extended ophthalmoscopy is performed during a global surgery period and is unrelated to the surgical condition, document the unrelatedness and report modifier -76 or -79 as appropriate.

Extended ophthalmoscopy (CPT 92201, 92202) is payable when documented as an extended ophthalmoscopy that meets indicated standards (e.g., includes a retinal drawing or equivalent documentation) beyond a general ophthalmologic exam.
Fundus photography (CPT 92227, CPT 92228) is covered when ordered by the treating physician or other treating practitioner acting within the scope of his/her license and Medicare requirements.
CPT 92227 is covered when used to evaluate asymptomatic patients at risk with known disease likely to cause retinal disease (e.g., diabetes mellitus) when ordered by the treating physician.
CPT 92228 is a covered service when ordered by the treating physician or other treating practitioner acting within the scope of license and Medicare requirements.
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.

CGS-J15-L34393, Ocular Photography - External

J15

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)

J18

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