Does H52.03 require prior authorization?

No, H52.03 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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`H52.03`, Hypermetropia, bilateral

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

No explicit documentation requirements are stated in this Background section of the policy.
Implicit documentation elements described across studies include acquisition and storage of AS-OCT images and quantitative measurements (e.g., AOD, ARA, TISA, ACD, CCT, flap thickness), comparison to reference standard exams (gonioscopy, UBM, USP), and clinical correlation (e.g., documentation of gonioscopy findings, clinical exam notes, indication for imaging).
No specific documentation requirements (medical record/test result documentation) are stated in this Clinical Policy Bulletin.
Claims must be submitted with the most appropriate diagnosis and procedure codes as of the effective date; claims submitted for services not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.

Key Coverage Criteria

Assessment of anterior chamber angle (ACA) configuration and detection of occludable/angle-closure (anterior segment OCT (AS-OCT) may be used for assessment of the anterior chamber angle and as a rapid screening tool for detection of occludable angles; cited studies include Nolan et al. 2007, Pekmezci et al. 2009, Desmond et al. 2022)
None. (The CPB states anterior segment OCT is considered experimental and investigational for all indications; see Limitations below.)
In vivo imaging and measurement of anterior segment ocular structures such as corneal and LASIK flap thickness (Visante OCT indication: "indicated for the in vivo imaging and measurement of ocular structures in the anterior segment such as corneal and laser in situ keratomileusis (LASIK) flap thickness (FDA, 2005).")
Measurement of central corneal thickness (CCT) and para-central corneal thickness (PCCT) (comparative studies vs ultrasound pachymetry and Orbscan II cited: Zhao et al. 2007; Li et al. 2007; Ho et al. 2007)
Quantitative assessment of anterior chamber parameters (AOD, ARA, TISA, ACD, angle metrics) for research and clinical evaluation (multiple reproducibility/measurement studies cited, e.g., Radhakrishnan et al. 2007; Maram et al. 2015)
Imaging and monitoring of trabeculectomy blebs and prediction of post-trabeculectomy outcomes (bleb parameter assessment, e.g., Singh et al. 2007; Kojima et al. 2015; Kokubun et al. 2018)

5 Active Policies

ANTHEM-CG-SURG-77, Refractive Surgery

AMBETTER-CP.VP.13, Preventative (Routine) Eye Examination

AMBETTER-CP.VP.13-Attachment-A-Refractive-Hardware, Preventive (Routine) Eye Examination Attachment A: Refractive Hardware

CIGNA-0125, Intraocular Lens Implant

AETNA-CPB-0749, Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging

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H52.03, Hypermetropia, bilateral