Does H35.00 require prior authorization?

No, H35.00 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H35.00` — Unspecified background retinopathy

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 medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
Panretinal (scatter) laser photocoagulation (PRP) is covered when medically necessary and supported by the Local Coverage Determination (LCD) and the patient's medical record.
Coverage for electroretinography (ERG) is determined by Local Coverage Determination (LCD) L37371; ERG is covered only when reasonable and necessary per LCD L37371.
Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.

L34615 — Visual Fields

J05

L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J05

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

J05

L37015 — Visual Electrophysiology Testing

J05

A57599

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