Does H40.9 require prior authorization?

No, H40.9 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`H40.9`, Unspecified glaucoma

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.
The medical record must document relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures sufficient to support medical necessity for the cataract extraction.

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.
Cataract extraction is covered when necessary to provide an unimpeded view of the fundus to allow proper management of posterior segment disease, with the cataract diagnosis billed as primary and the posterior segment disease as secondary.
Cataract extraction is covered for anisometropia when there is significant aniseikonia secondary to a prior cataract extraction with IOL implant and the aniseikonia is visually significant to the patient.
Complex cataract extraction (CPT 66982 and 66987) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery (e.g., capsular support devices, permanent intraocular sutures, extensive iris maneuvers, prosthetic iris placement, primary posterior capsulorhexis, treatment of phacolytic glaucoma, or other extraordinary operative/postoperative work).
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.

20 Active Policies

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

J15

CGS-J15-L33999, Corneal Pachymetry

J15

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

J15

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

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H40.9, Unspecified glaucoma