H20.21 — Lens-induced iridocyclitis, right eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
- Medical records must include patient weight when needed to determine appropriate dosing.
- Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
- Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
Key Coverage Criteria
- Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
- Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
- Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
- Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
- Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
- Cataract extraction is covered when necessary to provide an unimpeded view of the fundus to allow proper management of posterior segment disease, with the cataract diagnosis billed as primary and the posterior segment disease as secondary.
20 Active Policies
A57483 — Billing and Coding: Visual Fields
J05
A59805 — Billing and Coding: Cataract Surgery
J05
L34615 — Visual Fields
J05
L39905 — Cataract Surgery
J05
L39314 — Off-Label Use of Intravenous Immune Globulin (IVIG)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.