Does Q12.4 require prior authorization?

No, Q12.4 does not require prior authorization (high confidence). Covered without prior authorization.

`Q12.4`, Spherophakia

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures sufficient to support medical necessity for the cataract extraction.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When cataract extraction is performed to visualize the fundus, the record must identify the posterior segment disease and describe why visualization is necessary.
If cataract extraction is performed because of anisometropia, the record must document that aniseikonia is visually significant (patient subjective complaints) and must record refractive error measurements in both eyes after the first cataract surgery.

Cataract extraction is covered when necessary to provide an unimpeded view of the fundus to allow proper management of posterior segment disease, with the cataract diagnosis billed as primary and the posterior segment disease as secondary.
Cataract extraction is covered for anisometropia when there is significant aniseikonia secondary to a prior cataract extraction with IOL implant and the aniseikonia is visually significant to the patient.
Complex cataract extraction (CPT 66982 and 66987) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery (e.g., capsular support devices, permanent intraocular sutures, extensive iris maneuvers, prosthetic iris placement, primary posterior capsulorhexis, treatment of phacolytic glaucoma, or other extraordinary operative/postoperative work).
Ophthalmic biometry (CPT 76519 or 92136) is covered for preoperative intraocular lens (IOL) power calculation for patients undergoing cataract surgery.
Use diagnostic ultrasound A-scan (76519) for routine/simple cataract cases when performing IOL power calculation.
Use ultrasound B-scan (as clinically indicated) for patients with dense cataract where A-scan is not adequate for IOL power calculation.

CGS-J15-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J15

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

J15

CGS-J15-L33954, Cataract Extraction

J15

CGS-J18-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J18

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