Does H52.531 require prior authorization?

No, H52.531 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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`H52.531`, Spasm of accommodation, right eye

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

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.
Coverage determinations require consideration of the terms of the applicable benefit plan document, applicable laws/regulations, collateral source materials including Coverage Policies, and the specific facts of the situation; each coverage request should be reviewed on its own merits (instructional requirement for documentation review).
For anisometropia-related IOL coverage: clinical documentation demonstrating anisometropia of 2 diopters or greater and documentation that vision is uncorrectable with the use of glasses or contact lenses (i.e., refraction results and records of trial/use and intolerance or failure of corrective lenses).

Key Coverage Criteria

Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: following cataract extraction.
Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: trauma to the eye which has damaged the lens.
Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: congenital cataract.
Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: congenital aphakia.
Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: lens subluxation/displacement.
Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: anisometropia of 2 diopters or greater, and uncorrectable vision with the use of glasses or contact lenses.

3 Active Policies

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

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H52.531, Spasm of accommodation, right eye