Does H50.30 require prior authorization?

No, H50.30 does not require prior authorization (high confidence). Covered without prior authorization.

`H50.30`, Unspecified intermittent heterotropia

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the type of botulinum toxin used (Botox, Dysport, Xeomin, Myobloc) and the strength of the toxin administered.
The medical record must include a covered diagnosis or, if used for an indication not listed in the AHFS, a physician statement explaining why the unapproved form was used.
The medical record must state that traditional treatments were tried and proven unsuccessful, except for the specified conditions where such trials are not required.
The medical record must document the dosage used in the injections and the exact dosage given to the patient.

Botulinum toxin injections are covered when the medical record documents medical necessity consistent with the associated LCD Botulinum Toxin Types A and B (L35172).
Covered botulinum toxin preparations include onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and rimabotulinumtoxinB (Myobloc).
A statement that traditional methods of treatment have been tried and proven unsuccessful must be documented except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, or dysphonia where such trials are not required.
When electromyography (EMG) is performed to guide injections, documentation supporting the medical necessity of the EMG must be provided.
Documentation must support the clinical effectiveness of the injections and include a complete anatomic description of the injected site(s).
Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.

CGS-J15-L39857, Botulinum Toxin Injections

J15

CGS-J15-L39856, Botulinum Toxin Injections

J15

CGS-J18-L39856, Botulinum Toxin Injections

J18

CGS-J18-L39857, Botulinum Toxin Injections

J18

WPS-J5-L40381

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