Does H43.821 require prior authorization?

No, H43.821 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H43.821` — Vitreomacular adhesion, right eye

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 medical record must document relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures sufficient to support medical necessity for the cataract extraction.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
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.
Cataract extraction is covered for anisometropia when there is significant aniseikonia secondary to a prior cataract extraction with IOL implant and the aniseikonia is visually significant to the patient.
Complex cataract extraction (CPT 66982 and 66987) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery (e.g., capsular support devices, permanent intraocular sutures, extensive iris maneuvers, prosthetic iris placement, primary posterior capsulorhexis, treatment of phacolytic glaucoma, or other extraordinary operative/postoperative work).
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.

L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J05

L39905 — Cataract Surgery

J05

A59805 — Billing and Coding: Cataract Surgery

J05

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

J05

A57483

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