Does H11.042 require prior authorization?

No, H11.042 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H11.042` — Peripheral pterygium, stationary, left 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.
For diagnostic tests, report the test result on the claim if known; if the result is not known at time of billing, report the symptoms that prompted the test.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Computerized corneal topography is billable when performed as a diagnostic test for corneal conditions and the claim includes a diagnosis code that best describes the patient's condition for which the service was performed.
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.
Pre-operative corneal topography for intraocular lens power determination in cataract surgery when irregular astigmatism is present.

L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J06

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

J06

A56816 — Billing and Coding: Computerized Corneal Topography

A57068 — Billing and Coding: Ocular Photography - External

L34393 — Ocular Photography - External

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