Does Z90.01 require prior authorization?

No, Z90.01 does not require prior authorization (high confidence). Covered without prior authorization.

`Z90.01`, Acquired absence of eye

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must include the ordering/provider assessment related to the patient's complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
For Group 2 ICD-10-CM and Group 2 CPT codes, documentation must include visual field results and/or photographs supporting functional impairment.
For induction of visually compromising dermatochalasis by ptosis repair with large levator aponeurosis dehiscence, documentation must show the dehiscence and an operative note indicating skin excess after ptosis repair and necessity of blepharoplasty.
When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI; diagnostic test claims should report the test result or the symptoms prompting the test if the result is unknown.

Blepharoplasty is covered when medical necessity is documented in the medical record, including relevant history, physical exam, and diagnostic test results that support the procedure per the applicable LCD.
For Group 2 ICD-10-CM/CPT codes, coverage requires documentation of visual field testing results and/or photographs demonstrating functional visual impairment from eyelid pathology.
Blepharoplasty may be covered when visually compromising dermatochalasis is induced by ptosis repair in patients with large levator aponeurosis dehiscence if documentation shows the dehiscence and an operative note documents residual skin excess after ptosis repair that makes blepharoplasty necessary.
Aetna considers eye prostheses medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect.
Twice-yearly polishing and re-surfacing of eye prosthesis is medically necessary.
Replacement of an eye prosthesis is medically necessary every 5 years unless documentation supports the medical necessity of more frequent replacement.

CGS-J15-L33944, Blepharoplasty

J15

CGS-J18-L33944, Blepharoplasty

J18

ANTHEM-CG-SURG-03, Blepharoplasty, Blepharoptosis Repair, and Brow Lift

AETNA-CPB-0619, Eye Prosthesis

AETNA-CPB-0620, Facial Prostheses, External

Ask Backwork about documentation requirements, denial risks, or coverage in your state.