H52.00 — Hypermetropia, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- No explicit documentation requirements are stated in this Background section of the policy.
- Implicit documentation elements described across studies include acquisition and storage of AS-OCT images and quantitative measurements (e.g., AOD, ARA, TISA, ACD, CCT, flap thickness), comparison to reference standard exams (gonioscopy, UBM, USP), and clinical correlation (e.g., documentation of gonioscopy findings, clinical exam notes, indication for imaging).
- No specific documentation requirements (medical record/test result documentation) are stated in this Clinical Policy Bulletin.
- Appropriate ICD-10 diagnosis code(s) corresponding to a covered indication must be submitted with the procedural code(s).
Key Coverage Criteria
- Assessment of anterior chamber angle (ACA) configuration and detection of occludable/angle-closure (anterior segment OCT (AS-OCT) may be used for assessment of the anterior chamber angle and as a rapid screening tool for detection of occludable angles; cited studies include Nolan et al. 2007, Pekmezci et al. 2009, Desmond et al. 2022)
- None. (The CPB states anterior segment OCT is considered experimental and investigational for all indications; see Limitations below.)
- In vivo imaging and measurement of anterior segment ocular structures such as corneal and LASIK flap thickness (Visante OCT indication: "indicated for the in vivo imaging and measurement of ocular structures in the anterior segment such as corneal and laser in situ keratomileusis (LASIK) flap thickness (FDA, 2005).")
- Measurement of central corneal thickness (CCT) and para-central corneal thickness (PCCT) (comparative studies vs ultrasound pachymetry and Orbscan II cited: Zhao et al. 2007; Li et al. 2007; Ho et al. 2007)
- Quantitative assessment of anterior chamber parameters (AOD, ARA, TISA, ACD, angle metrics) for research and clinical evaluation (multiple reproducibility/measurement studies cited, e.g., Radhakrishnan et al. 2007; Maram et al. 2015)
- Imaging and monitoring of trabeculectomy blebs and prediction of post-trabeculectomy outcomes (bleb parameter assessment, e.g., Singh et al. 2007; Kojima et al. 2015; Kokubun et al. 2018)
7 Active Policies
AMBETTER-CP.VP.13-Attachment-A-Refractive-Hardware — Preventive (Routine) Eye Examination Attachment A: Refractive Hardware
CIGNA-0125 — Intraocular Lens Implant - (0125)
AETNA-CPB-0023 — Corneal Remodeling
AETNA-CPB-0689 — Ocular Photoscreening
AETNA-CPB-0749 — Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging
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