Does H27.01 require prior authorization?

No, H27.01 does not require prior authorization (high confidence). Covered without prior authorization.

`H27.01`, Aphakia, right eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The diagnosis code that justifies medical need must be included on the claim for refractive lenses and related items.
Final Rule 1713 items require a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes; claims lacking face-to-face and WOPD per the LCD will be denied and items delivered before receipt of a WOPD will be denied.
For anti-reflective coating (V2750), tints (V2744,V2745), oversized lenses (V2780), and polycarbonate/Trivex (V2784) when used for medical necessity (and V2784 for monocular vision), the KX modifier must be added and supporting medical necessity documentation must be available upon request; if criteria are not met the GA or GZ modifier must be used (GA if a valid ABN is on file, GZ if not).
Claim lines for anti-reflective coating, tints, oversized lenses or polycarbonate/Trivex billed without a KX, GA or GZ modifier will be rejected as missing information.

Refractive lenses are covered when used to restore vision normally provided by the natural lens in individuals who lack the organic lens because of surgical removal or congenital absence.
Coverage of refractive lenses applies even if the surgical removal of the natural lens occurred before Medicare entitlement.
Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Ophthalmic biometry (CPT 76519 or 92136) is covered for preoperative intraocular lens (IOL) power calculation for patients undergoing cataract surgery.
Use diagnostic ultrasound A-scan (76519) for routine/simple cataract cases when performing IOL power calculation.
Use ultrasound B-scan (as clinically indicated) for patients with dense cataract where A-scan is not adequate for IOL power calculation.

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

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CGS-J15-L34393, Ocular Photography - External

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

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CGS-J18-L34393, Ocular Photography - External

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