Does H05.261 require prior authorization?

No, H05.261 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H05.261` — Pulsating exophthalmos, right eye

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
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.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.

L34615 — Visual Fields

J05

A57483 — Billing and Coding: Visual Fields

J05

L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J06

L33574 — Visual Fields Testing

J06

A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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