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ICD-10-CM P07.15, Other low birth weight newborn, 1250-1499 grams | No Prior Auth

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`P07.15`, Other low birth weight newborn, 1250-1499 grams

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Detailed drawing(s) of views of the patient's retina(s) and any defects documented in the medical record.
Record of the examination method used (direct vs indirect; contact lens, H‑ruby lens, or 90‑diopter lens), which eye(s) were examined, and identity/licensure of the performing eye care provider.
Detailed retinal drawing (disc, macula or periphery) accompanied by an interpretation and report.
Drawing must be anatomically specific to the patient, clearly labeled, and of sufficient size (no less than 3–4 inches in diameter).

Key Coverage Criteria

Infants undergoing treatment and/or monitoring of retinopathy of prematurity.
Histoplasmosis affecting the eye requiring detailed ophthalmoscopic evaluation.
Choroidal neoplasms requiring extended retinal imaging or evaluation.
Glaucoma when extended ophthalmoscopy is needed for assessment or monitoring.
Optic nerve pathology requiring detailed ophthalmoscopic examination.
Diabetic retinopathy requiring extended ophthalmoscopy for diagnosis or monitoring.

1 Active Policy

AMBETTER-CP.VP.26, Extended Ophthalmoscopy

Related Codes

92202(1 policies)A18.53(1 policies)A18.54(1 policies)B39.4(1 policies)B39.5(1 policies)B58.01(1 policies)C69.21(1 policies)92201(1 policies)

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Scaled drawing must accurately represent normal, abnormal, and common findings (examples: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, retinal detachments, holes, tears, tumors).

When used to define optic nerve changes, ancillary drawings of cup-to-disc data elements are required (size, depth, rim, vessels, coloration).