H43.10 — Vitreous hemorrhage, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For clinical use as presented in the literature, documentation should include the imaging modality and device used, numerical values for the measured parameter(s) (e.g., ONSD in mm, RNFL/GCIPL thickness in µm, OCTA vessel density %), measurement technique and timing (e.g., relation to ROSC or symptom onset), and image quality metrics or notes on artifacts.
- Accepted optic nerve and retinal imaging methods include the following: Confocal laser scanning ophthalmoscopy; Nerve fiber layer testing or analysis (confocal laser scanning tomography with polarimetry); Optical coherence tomography (OCT); Stereophotogrammetry.
- In addition to annual screening that should begin after 5 years of use (or sooner if there are unusual risk factors), a baseline study of optic nerve and retinal imaging is considered medically necessary before initiation of chloroquine, hydroxychloroquine, or vigabatrin therapy.
Key Coverage Criteria
- Age-related macular degeneration
- Pseudotumor cerebri
- B58.01 Toxoplasma chorioretinitis
- C69.20 - C69.32 Malignant neoplasm of the retina and choroid
- D18.09 Hemangioma of other sites [retina]
- B50.0 - B54 Malaria
2 Active Policies
AETNA-CPB-0344 — Optic Nerve and Retinal Imaging Methods
AETNA-CPB-0393 — Vitrectomy
Related Codes
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