Does S05.8X9A require prior authorization?

No, S05.8X9A does not require prior authorization (high confidence). Covered without prior authorization.

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`S05.8X9A`, Other injuries of unspecified eye and orbit, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Medical record documentation must demonstrate the clinical indication for SCODI/OCT (diagnostic or management purpose) and supporting clinical findings.

For cataract-related OCT codes in patients with prior refractive surgery, the patient record must contain documentation of the prior refractive procedure to qualify for reimbursement.

Gonioscopy documentation is required to support use of anterior segment OCT for evaluation of narrow angle, suspected narrow angle, mixed-angle glaucoma, or angle recession.

Key Coverage Criteria

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Posterior segment OCT is reasonable and necessary to diagnose and manage retinal and neuro-ophthalmic diseases involving the optic nerve, subretinal and intraretinal abnormalities, vitreoretinal relationships, or retinal nerve fiber layer changes.
Posterior segment OCT is reasonable and necessary to diagnose early glaucoma and to monitor glaucoma treatment.
Posterior segment OCT may be used to differentiate causes of optic nerve disorders when the diagnosis is uncertain.
Posterior segment OCT may be used to diagnose or manage the patient when visual field results are insufficient or reliable visual field testing cannot be performed due to visual, physical, mental, or age-related constraints.
Posterior segment OCT is indicated to evaluate discrepancies between clinical optic nerve appearance and visual field results.

3 Active Policies

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A56537, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

NGS-JK-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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S05.8X9A, Other injuries of unspecified eye and orbit, initial encounter