Does H04.131 require prior authorization?

No, H04.131 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H04.131` — Lacrimal cyst, right lacrimal gland

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.
An interpretation and report specific to the photograph(s), including comparison to prior photographs when available, must be maintained in the medical record and available to the contractor upon request.
If additional photographs are taken to track changes, written documentation describing those changes must be maintained in the patient's medical record.

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.
External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
External ocular photography is covered when photo-documentation is required to track progression or lack of progression of an eye condition or to document response or progression related to a course of treatment.
External ocular photography is covered when a special camera is used to obtain magnified medical-quality photographs of lesions (e.g., cornea, iris, eyelids) for the purpose of following the patient's condition.
External ocular photography is medically necessary to track progression of external ocular conditions affecting the external eye, eyelids, and ocular adnexa.

AMBETTER-CP.VP.43 — External Ocular Photography

A57068 — Billing and Coding: Ocular Photography - External

L34393 — Ocular Photography - External

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