H15.129 — Nodular episcleritis, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Inferred: for evaluations labeled as 'once' (evaluation of complications of corneal refractive surgery; testing for glaucoma suspects once per lifetime), documentation should record date(s) of prior pachymetry to substantiate frequency limits.
- Inferred: for persons 'who recently had laser iridotomy' documentation of prior laser iridotomy and reason for testing should be present.
- Inferred: for corneal transplant pre- and post-operative evaluations and for evaluation of corneal rejection, medical/surgical records documenting transplant status, signs/symptoms of rejection, and treatment/response should be included.
- Inferred: clinical documentation must support one of the covered indications/diagnoses listed in the policy (e.g., documentation of corneal disease for pre-operative cataract work-up to justify pachymetry).
Key Coverage Criteria
- Fuchs' endothelial dystrophy
- Persons who recently had laser iridotomy for the treatment of narrow angle glaucoma (also known as acute angle-closure glaucoma or closed-angle glaucoma)
- Anatomical narrow angles
- Bullous keratopathy
- Corneal edema
- Corneal refractive surgery (pre- and post-operative evaluation)
3 Active Policies
AETNA-CPB-0681 — Corneal Pachymetry
AETNA-CPB-0719 — Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
AETNA-CPB-0734 — External Ocular Photography
Related Codes
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