Does H52.32 require prior authorization?

No, H52.32 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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`H52.32`, Aniseikonia

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

Medical record must contain a chief complaint documenting symptoms (e.g., blurred vision, reduced contrast sensitivity, glare) associated with impaired functionality and include the patient's own words where possible.
A unique statement describing the specific symptomatic impairment of visual function that results in inability to perform ADLs must be recorded; optional VF-14 or VF-8R visual activities questionnaires (one per eye) may be used to document this.
Record best-corrected Snellen visual acuity at distance (and near if relevant) as determined by a careful refraction performed under standard testing conditions; refraction may be performed by the surgeon or qualified staff as permitted by law.
Document the degree of lens opacity and correlate it with the impairment; include findings from a full ophthalmic evaluation that support cataract as the primary cause of visual compromise.

Key Coverage Criteria

Cataract surgery is indicated when the patient has a symptomatic visual impairment (e.g., blurred vision, reduced contrast sensitivity, glare) that results in inability to function satisfactorily in Activities of Daily Life (reading, television, driving, vocational/recreational tasks).
Documented best-corrected Snellen visual acuity (distance, and near if primary impairment is near) determined by a careful refraction under standard testing conditions demonstrating that the visual impairment cannot be corrected with a tolerable change to glasses or contact lenses.
Cataract surgery is indicated when there is a degree of lens opacity documented that correlates with the impairment of best-corrected visual acuity and cataract is determined to be the most likely primary cause of visual compromise after full ophthalmic evaluation.
When concomitant ocular disease (e.g., macular degeneration, diabetic retinopathy) may affect vision, surgery is indicated if documentation states cataract significantly contributes to the impairment or that surgery is required to establish clear media for treatment/monitoring of the coexisting condition.
Cataract surgery is indicated when there is documentation that the patient desires surgical correction and that risks, benefits, and alternatives have been explained, including a statement if vision improvement is not expected and the patient understands that.
Use of CPT 66982 (complex cataract surgery) is indicated only when the procedure requires devices or techniques not generally used in routine cataract surgery and the operative note provides clear justification (examples: suturing a posterior chamber IOL due to insufficient capsular support; iris hooks for severe miosis; trypan blue for mature cataract).

9 Active Policies

WPS-J5-L39905, Cataract Surgery

A59805, Billing and Coding: Cataract Surgery

WPS-J8-L39905, Cataract Surgery

AMBETTER-CP.VP.06, Medically Necessary Optical Hardware

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

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H52.32, Aniseikonia