Does H57.04 require prior authorization?

No, H57.04 does not require prior authorization (high confidence). Covered without prior authorization.

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`H57.04`, Mydriasis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient medical record must include the ordering provider's assessment related to the patient's complaint for that visit, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
For diagnostic tests, report the test result on the claim if known; if result is not known, report the symptoms that prompted the test.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Advance Beneficiary Notice (ABN) requirements: Form CMS-R-131 must be signed by the beneficiary when applicable; for Part A MAC claims, occurrence code 32 and the date of the ABN must be submitted.

Key Coverage Criteria

CPT 66982 (complex cataract extraction) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery.
For diagnoses H20.21-H20.23, H21.261-H21.263, H21.29, or H21.561-H21.563, CPT 66982 may be billed if the operative note documents use of an endocapsular ring to partially occlude the pupil.
For diagnoses H21.271-H21.273, H26.211-H26.213, or H26.221-H26.223, CPT 66982 may be billed if the operative note documents micro iris hooks inserted through four separate corneal incisions, a Beehler or similar expansion device, synechialysis with papillary stretch maneuvers, multiple sphincterotomies with scissors, or sector iridotomy with suture repair of the iris sphincter.
For diagnoses H21.221-H21.223, CPT 66982 may be billed if the operative note documents use of a permanent intraocular suture or a capsular support ring to place the intraocular lens in a stable position.
For diagnoses H21.531-H21.533, CPT 66982 may be billed if the operative note documents employment of a capsular support ring or an endocapsular support ring for partial occlusion of the pupil.
For the broad set of diagnoses including H21.81, H21.89, H21.9, H22, H25.x, H26.x, E08.36-E13.36, and Q13.0/Q13.2, CPT 66982 may be billed if the operative note documents interventions such as micro iris hooks (four incisions), Beechler-type expansion devices, synechialysis with papillary stretch, multiple sphincterotomies, sector iridotomy with suture repair, permanent intraocular sutures, capsular support rings, or endocapsular rings as noted in the operative report.

17 Active Policies

CGS-J15-L33954, Cataract Extraction

J15

CGS-J15-L37578, Micro-Invasive Glaucoma Surgery (MIGS)

J15

CGS-J18-L37578, Micro-Invasive Glaucoma Surgery (MIGS)

J18

CGS-J18-L33954, Cataract Extraction

J18

A59805, Billing and Coding: Cataract Surgery

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H57.04, Mydriasis