Does H02.004 require prior authorization?

No, H02.004 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H02.004` — Unspecified entropion of left upper eyelid

ICD-10-CM

No Prior Auth Required

Code is 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.
Full policy text not provided; specific clinical indications for blepharoplasty, eyelid surgery, and brow lift cannot be extracted from the supplied content.
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).
External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.

L34528 — Blepharoplasty, Blepharoptosis and Brow Lift

J05

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

J05

A57637 — Billing and Coding: Visual Field Examination

J09

L33766 — Visual Field Examination

J09

L34411 — Blepharoplasty, Eyelid Surgery, and Brow Lift

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