Does H40.001 require prior authorization?

No, H40.001 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`H40.001`, Preglaucoma, unspecified, right eye

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

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.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Key Coverage Criteria

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Corneal pachymetry (measurement of corneal thickness) is covered to evaluate patients with a diagnosis of increased intraocular pressure.
Repeat corneal pachymetry is covered after interval corneal trauma or corneal surgery to reassess corneal thickness.
Corneal pachymetry is generally covered when performed as indicated by current medical literature or accepted standards of practice for clinical management.
Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.

20 Active Policies

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

J15

CGS-J15-L33999, Corneal Pachymetry

J15

CGS-J15-L34394, Visual Fields Testing

J15

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

J15

Have a follow-up question?

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

Ask Backwork about H40.001 Sign up free

H40.001, Preglaucoma, unspecified, right eye