Does T26.00XA require prior authorization?

No, T26.00XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T26.00XA`, Burn of unspecified eyelid and periocular area, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

List the appropriate CPT code for the procedure and include any applicable modifiers; adhere to Medicare global surgery and CCI (correct coding initiative) rules for eyelid surgeries.
Submit physicians' services and diagnostic tests with a diagnosis code that supports medical necessity and code to the greatest level of specificity (full digit completeness).
Use the diagnosis code based on diagnostic test results as the primary diagnosis; if test results are normal or inconclusive, use the diagnosis code for the sign or symptom that prompted the test as the primary diagnosis.

When signs or symptoms are present, place the appropriate definitive diagnosis code in the first position and an available symptom diagnosis code in the second position on CMS-1500 item 21 (or electronic equivalent).

When a patient requests submission of cosmetic services to Medicare, report with modifier GY and place ICD-10 code Z41.1 in the first diagnosis position on the claim; consider issuing a Notice of Exclusion from Medicare Benefits (NEMB) as appropriate.

The article provides billing/coding guidance that complements LCD L39400; use the documentation, prior authorization, and claim submission requirements specified in LCD L39400 and the local contractor's instructions.

Key Coverage Criteria

Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
Keratoprosthesis using the Dohlman Doane Boston KPro (“Boston KPro”) device is consideredmedically necessaryfor the treatment of corneal blindness wheneitherof the following criteria are met (AorB):
For individuals with prior corneal transplant:The cornea is severely opaque and vascularized;andThere is documentation of at least one prior failed corneal transplant procedure;or
The cornea is severely opaque and vascularized;and
There is documentation of at least one prior failed corneal transplant procedure;or

5 Active Policies

WPS-J5-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

A56908, Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

WPS-J8-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

ANTHEM-CG-SURG-94, Keratoprosthesis

A59186, Billing and Coding: Magnesium

`T26.00XA`, Burn of unspecified eyelid and periocular area, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

T26.00XA, Burn of unspecified eyelid and periocular area, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`T26.00XA`, Burn of unspecified eyelid and periocular area, initial encounter