Does H21.81 require prior authorization?

No, H21.81 does not require prior authorization (high confidence). Covered without prior authorization.

`H21.81`, Floppy iris syndrome

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures sufficient to support medical necessity for the cataract extraction.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When cataract extraction is performed to visualize the fundus, the record must identify the posterior segment disease and describe why visualization is necessary.
If cataract extraction is performed because of anisometropia, the record must document that aniseikonia is visually significant (patient subjective complaints) and must record refractive error measurements in both eyes after the first cataract surgery.

Cataract extraction is covered when necessary to provide an unimpeded view of the fundus to allow proper management of posterior segment disease, with the cataract diagnosis billed as primary and the posterior segment disease as secondary.
Cataract extraction is covered for anisometropia when there is significant aniseikonia secondary to a prior cataract extraction with IOL implant and the aniseikonia is visually significant to the patient.
Complex cataract extraction (CPT 66982 and 66987) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery (e.g., capsular support devices, permanent intraocular sutures, extensive iris maneuvers, prosthetic iris placement, primary posterior capsulorhexis, treatment of phacolytic glaucoma, or other extraordinary operative/postoperative work).
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.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.

CGS-J15-L37578, Micro-Invasive Glaucoma Surgery (MIGS)

J15

CGS-J15-L33954, Cataract Extraction

J15

CGS-J15-L34393, Ocular Photography - External

J15

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

J15

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