Does Z02.89 require prior authorization?

No, Z02.89 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z02.89`, Encounter for other administrative examinations

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Document patient age to demonstrate eligibility for screening (e.g., 3 years of age; 4–5 years with inability to cooperate).
Document evidence of inability to cooperate with routine acuity screening for children 4 to 5 years old when applicable (examples given: intellectual disability, developmental delay, severe behavioral disorders).
Document that photoscreening was performed (including type of instrument and whether remote or on-site analysis was used) and result (normal/abnormal/unreadable).

Document referral for a complete eye examination when photoscreening findings are abnormal.

Supportive coding/diagnosis must align with covered ICD-10 codes listed in policy when billing (see covered ICD-10 code list).

Documentation of clinical concern for symptomatic COVID-19 infection (e.g., symptoms consistent with COVID-19) when ordering molecular or antigen testing.

Key Coverage Criteria

Aetna considers one ocular photoscreening medically necessary for screening all children 3 years of age.
Aetna considers one ocular photoscreening medically necessary for screening children 4 to 5 years of age who are unable to cooperate with routine acuity screening (e.g., intellectual disability, developmental delay, and severe behavioral disorders).
CPT codes covered if selection criteria are met: 99174 (Instrument-based ocular screening (eg, photoscreening, automated refraction), bilateral; with remote analysis and report) and 99177 (with on-site analysis).
ICD-10 codes covered if selection criteria are met (not all-inclusive): H53.001 - H54.8 (Visual disturbances, blindness and low vision).
ICD-10 codes covered if selection criteria are met (not all-inclusive): P07.00 - P07.32 (Disorders of newborn related to short gestation and low birth weight, not elsewhere classified).
ICD-10 codes covered if selection criteria are met (not all-inclusive): Z00.129 (Encounter for routine child health examination without abnormal findings).

2 Active Policies

CIGNA-0557, COVID-19: In Vitro Diagnostic Testing

AETNA-CPB-0689, Ocular Photoscreening

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Z02.89, Encounter for other administrative examinations