Does H40.1131 require prior authorization?

No, H40.1131 does not require prior authorization (high confidence). Covered without prior authorization.

`H40.1131`, Primary open-angle glaucoma, bilateral, mild stage

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document the diagnosis and clinical indication (e.g., increased intraocular pressure, Fuchs dystrophy, ocular trauma, surgical history) and that the pachymetry is integral to medical management.
Provider/supplier must notify the beneficiary in writing prior to rendering the service if the provider is aware the test may not be covered by Medicare.
Services must be performed by or ordered/certified by ophthalmologists or optometrists or by authorized non-physician practitioners as allowed by state law, and that authority should be documented.
For Part A MAC claims and FQHC services, use appropriate bill type codes (e.g., bill type 77X for FQHC services for dates of service on/after April 1, 2010) and document billing per MAC guidance.

Corneal pachymetry is covered to determine the amount of endothelial trauma sustained during ocular surgery.
Corneal pachymetry is covered for pre-operative assessment of corneal health in patients with Fuchs dystrophy.
Corneal pachymetry is covered for assessment of corneal thickness after ocular trauma.
Corneal pachymetry is covered to assess corneal thickness in suspected glaucoma following a documented diagnosis of increased intraocular pressure prior to initiation of a glaucoma treatment regimen.
Coverage requires the test to be integral to the patient's medical management decision-making and performed by an ophthalmologist or optometrist.
When corneal disease is suspected and supported by diagnosis, pachymetry may be performed at the same time as endothelial cell count.

CGS-J15-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J15

CGS-J15-L33999, Corneal Pachymetry

J15

CGS-J15-L34394, Visual Fields Testing

J15

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

J15

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