Does H25.091 require prior authorization?

No, H25.091 does not require prior authorization (high confidence). Covered without prior authorization.

`H25.091`, Other age-related incipient cataract, right eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

When billing ICD-10 codes H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, H26.231, H26.232, H26.233, E08.36, E09.36, E10.36, E11.36, E13.36, or H28, the ICD-10 code for the underlying condition must be listed and coded first on the claim.
When billing ICD-10 codes H26.31, H26.32, H26.33, or H26.8, the causative agent must be identified on the claim.
All documentation must be maintained in the patient's medical record, be legible, include patient identification (e.g., full name, dates of service), and be available to the contractor upon request.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.

Cataract extraction is covered when the physician performing the preoperative ophthalmologic evaluation lists cataract as the primary diagnosis (ICD-10-CM codes per LCD L35091).
Preoperative evaluation and management (E/M) services are covered when the evaluating clinician documents cataract as the primary or secondary diagnosis when medically necessary.
Complex cataract extraction is covered when the procedure requires insertion of iris retractors through additional incisions to maintain or improve exposure.
Complex cataract extraction is covered when mechanical expansion of the pupil is performed using iris hooks.
Complex cataract extraction is covered when a sector iridectomy is created with subsequent suture repair of the iris sphincter.
Complex cataract extraction is covered when an intraoperative iris expansion device (e.g., Malyugin ring) is used to maintain pupil dilation.

CGS-J15-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J15

CGS-J18-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J18

FIRST_COAST-L38926, Cataract Extraction (including Complex Cataract Surgery)

A58592, Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)

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