Does H35.461 require prior authorization?

No, H35.461 does not require prior authorization (high confidence). Covered without prior authorization.

`H35.461`, Secondary vitreoretinal degeneration, right eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
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.