Does H35.013 require prior authorization?

No, H35.013 does not require prior authorization (high confidence). Covered without prior authorization.

`H35.013`, Changes in retinal vascular appearance, bilateral

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
The diagnosis code(s) submitted must best describe the patient's condition for which the service was performed and must be a valid ICD-10-CM code.
Use modifiers LT/RT to indicate the operative site and use modifier -50 if both eyes are treated on the same day/session.

Panretinal (scatter) laser photocoagulation (PRP) is covered when medically necessary and supported by the Local Coverage Determination (LCD) and the patient's medical record.
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).

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

J15

CGS-J15-L34394, Visual Fields Testing

J15

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

J15

CGS-J15-L38992, Electroretinography (ERG)

J15

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