Does H35.81 require prior authorization?

No, H35.81 does not require prior authorization (high confidence). Covered without prior authorization.

`H35.81`, Retinal edema

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.

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).
Patient has a cataract causing impairment of visual function with decreased ability to perform activities of daily living (e.g., reading, watching television, driving, occupational/vocational tasks).

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

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J15-L38992, Electroretinography (ERG)

J15

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

J15

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