Does H52.11 require prior authorization?

No, H52.11 does not require prior authorization (high confidence). Covered without prior authorization.

`H52.11`, Myopia, right eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Record visual acuity with current correction (power documented) at distance and, when appropriate, at near; include refraction when indicated.
Document visual fields by confrontation or automated screening devices (non-threshold).
Document external examination findings: eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent facial features.
Document pupillary function: size, light response, and assessment for relative afferent pupillary defect.

Routine preventive ophthalmic evaluation to detect common and serious ocular abnormalities.
Periodic re-examination of all patients, with emphasis on those who have risk factors for ocular disease, to prevent or minimize vision loss through early detection and treatment.
Preventive (routine) eye examinations to evaluate the visual system and related ocular structures.
Periodic re‑examination after an initial comprehensive exam that is normal or only shows refractive (optical) abnormalities to detect new or asymptomatic ocular disease (examples: glaucoma, diabetic retinopathy, age‑related macular degeneration).
Comprehensive evaluations for patients with no risk factors at routine intervals (frequencies specified elsewhere in the policy).
Pediatrics: follow CPG.VP.47 Pediatric Eye Examinations.

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

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

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