Does H50.631 require prior authorization?

No, H50.631 does not require prior authorization (high confidence). Covered without prior authorization.

`H50.631`, Inferior rectus muscle entrapment, right eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.
Medical records must document the exact type and strength of botulinum toxin used (Botox, Dysport, Xeomin, or Myobloc) and the dosage administered.
Medical records must include a covered diagnosis per the LCD (or a physician statement explaining use for an indication not listed in the AHFS) and support for clinical effectiveness of the injections.
Except for the enumerated exceptions (focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, dysphonia), the record must state that traditional methods of treatment have been tried and proven unsuccessful.

No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
Botulinum toxin injections are covered when medical necessity is documented according to the Local Coverage Determination (LCD) 'Botulinum Toxin Types A and B' Indications and Limitations of Coverage.
Approved formulations include Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA), and Myobloc (rimabotulinumtoxinB); when a formulation is used for an indication not listed in the AHFS, a physician statement explaining the reason(s) for the unapproved form must be in the medical record.
Focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, and dysphonia are recognized indications for which prior failure of traditional therapies is not required to document medical necessity.
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).

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-L34594

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