Does H55.01 require prior authorization?

No, H55.01 does not require prior authorization (high confidence). Covered without prior authorization.

`H55.01`, Congenital nystagmus

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.
Documentation should include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures supporting the need for visual fields testing.
The diagnosis code(s) reported on the claim must best describe the patient's condition for which the visual fields testing was performed.
Refer to NCCI and OPPS requirements prior to billing Medicare to ensure coding compliance and to determine any bundling or packaging edits.

No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
If the service requires a referring/ordering physician, include the ordering/referring physician’s name and NPI on the claim.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

A57483, Billing and Coding: Visual Fields

WPS-J5-L34615, Visual Fields

A56551, Billing and Coding: Visual Fields Testing

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