Does H35.123 require prior authorization?

No, H35.123 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H35.123` — Retinopathy of prematurity, stage 1, bilateral

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
The diagnosis code(s) submitted must best describe the patient's condition for which the service was performed and must be a valid ICD-10-CM code.
Use modifiers LT/RT to indicate the operative site and use modifier -50 if both eyes are treated on the same day/session.

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.
Conditions including tuberculosis of eye (A18.53, A18.54), diabetes mellitus with ophthalmic complications (E08.311-E08.359, E09.311-E09.359, E10.311-E10.359, E11.311-E11.359, E13.311-E13.359), ophthalmia nodosa (H16.241-H16.249), selected anterior segment disorders (H20.00-H21.1X1), and transient cerebral ischemic attacks with ocular involvement (G45.3) may require extended ophthalmoscopy and are covered.

A57599 — Billing and Coding: Visual Electrophysiology Testing

J05

L34615 — Visual Fields

J05

A57483 — Billing and Coding: Visual Fields

J05

L37015 — Visual Electrophysiology Testing

J05

L33567 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

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