Does H33.012 require prior authorization?

No, H33.012 does not require prior authorization (high confidence). Covered without prior authorization.

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`H33.012`, Retinal detachment with single break, left eye

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims for SCODI must be submitted to the Part B MAC; bill all same‑day services for the same beneficiary/provider on the same claim.
Use CPT codes 92133 and 92134 and report the technical component with modifier TC and the professional component with modifier 26 as appropriate on claims.
Follow the coverage, medical necessity, and documentation requirements detailed in LCD L34760 for clinical indications and supporting medical records.
Refer to Medicare Claims Processing Manual 100-04, Chapter 32, Section 300.2 for claims processing requirements relevant to ophthalmic procedures (e.g., OPT with Verteporfin) on professional and outpatient facility claims.

Key Coverage Criteria

SCODI (CPT 92133, 92134) is considered medically reasonable and necessary for evaluation of retinal disorders, glaucoma, and anterior segment disorders as documented in LCD L34760.
Taped and un-taped visual field testing count as one unit of service for MUE (medically unlikely edits) purposes.
Global visual field services (technical plus professional) are payable under Medicare Part B when billed in place of service: Office (11), Nursing Facility (32), and Independent Clinic (49).
The technical component of visual field testing is payable under Medicare Part B when billed in place of service: Office (11), Nursing Facility (32), Independent Clinic (49), Federally Qualified Health Center (50), and Rural Health Clinic (72).
The professional component of visual field testing is payable under Medicare Part B when billed in place of service: Office (11), Off-campus Outpatient Hospital (19), Inpatient Hospital (21), On-campus Outpatient Hospital (22), Emergency Room (23), Skilled Nursing Facility (31), Nursing Facility (32), Independent Clinic (49), and Comprehensive Outpatient Rehabilitation Facility (62).
Cataract causing impaired vision with documented symptomatic impairment of visual function that prevents satisfactory performance of activities of daily living (e.g., reading, driving); include the patient's chief complaint and a unique statement (patient's own words when possible) and record best-corrected Snellen visual acuity at distance (and near if applicable) by a careful refraction.

20 Active Policies

CGS-J15-L34394, Visual Fields Testing

J15

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

J15

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

J15

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

J15

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H33.012, Retinal detachment with single break, left eye