H04.129 — Dry eye syndrome of unspecified lacrimal gland
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the patient's diagnosis meets one of the covered indications (e.g., chronic neck pain or chronic headache with minimum 12 weeks duration where applicable).
- Documentation of duration of symptoms when chronicity is required (policy explicitly requires minimum 12 weeks duration for chronic neck pain and chronic headache).
- Documentation of clinical response: if no clinical benefit after four weeks of acupuncture, the treatment plan should be reevaluated; further treatment is not medically necessary if the member does not demonstrate meaningful improvement in symptoms.
- Provider credentialing/license documentation showing the acupuncture is administered by a health care provider practicing within the scope of his/her license (and, where applicable by specific plans, documentation that provider is a legally qualified physician practicing within scope of license).
Key Coverage Criteria
- Plantar Fasciitis
- Peptic Ulcer
- Post-Operative Ileus
- Post-Prandial Distress Syndrome
- Post-Stroke Shoulder Pain
- Premature Ejaculation
4 Active Policies
AETNA-CPB-0029 — Thermography
AETNA-CPB-0135 — Acupuncture and Dry Needling
AETNA-CPB-0344 — Optic Nerve and Retinal Imaging Methods
ANTHEM-CG-SURG-94 — CG-SURG-94 Keratoprosthesis
Related Codes
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