Does H16.043 require prior authorization?

No, H16.043 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H16.043` — Marginal corneal ulcer, bilateral

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.
Claims for SCODI must be submitted to the Part B MAC; bill all same‑day services for the same beneficiary/provider on the same claim.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
SCODI (CPT 92133, 92134) is considered medically reasonable and necessary for evaluation of retinal disorders, glaucoma, and anterior segment disorders as documented in LCD L34760.
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.
Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.

A56916 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J05

L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J05

L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J06

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

J06

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