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ICD-10-CM H53.049, Amblyopia suspect, unspecified eye | No Prior Auth

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`H53.049`, Amblyopia suspect, unspecified eye

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information such as complete name and dates of service.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Key Coverage Criteria

Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
Repair of a functional defect caused by trauma, tumor, or surgery;or
Periorbital sequelae of thyroid disease;or
Nerve palsy.
Occlusion Amblyopia (also known as deprivation amblyopia)
Upper eyelid blepharoplasty or blepharoptosis repair is consideredmedically necessaryto treat occlusion amblyopia when BOTH of the following criteria are met:

3 Active Policies

FIRST_COAST-L33766, Visual Field Examination

J9

A57637, Billing and Coding: Visual Field Examination

J9

ANTHEM-CG-SURG-03, Blepharoplasty, Blepharoptosis Repair, and Brow Lift

Related Codes

H02.401(3 policies)H02.59(3 policies)H02.30(3 policies)H02.36(3 policies)H02.439(3 policies)H02.511(3 policies)E05.00(3 policies)H02.831(3 policies)

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The submitted CPT/HCPCS code must accurately describe the service performed.

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation and retain copies of the ordering/referring physician’s order for the studies.