H52.4 — Presbyopia
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Appropriate ICD-10 diagnosis code(s) corresponding to a covered indication must be submitted with the procedural code(s).
- For Artisan phakic IOLs: documentation of myopia range (-5 to -20 D), astigmatism <= 2.5 D at spectacle plane, anterior chamber depth (ACD) >= 3.2 mm, and documented stability of refraction for the prior 6 months (spherical equivalent change <= 0.50 D).
- For Visian ICL: documentation of age (21 to 45 years), myopia range (-3.0 to <= -15.0 D or reduction of > -15.0 to -20.0 D), astigmatism <= 2.5 D at spectacle plane, ACD >= 3.00 mm, and a stable refractive history within 0.5 D for 1 year prior to implantation.
- For conductive keratoplasty: documentation that patient is at least 40 years old, has mild to moderate hyperopia (0.75 to 3.25 D), has <= 0.75 D astigmatism, and eyesight changed < 0.50 D in previous 12 months.
Key Coverage Criteria
- Correction of surgically induced astigmatism with a corneal relaxing incision (including limbal relaxing incisions) or corneal wedge resection when both of the following criteria are met: The member had previous penetrating keratoplasty (corneal transplant) within the past 60 months or cataract surgery within the last 36 months; AND both of the following criteria are met: The degree of astigmatism must be 3.00 diopters or greater; and The member must be intolerant of glasses or contact lenses.
- Phototherapeutic keratectomy (PTK) is medically necessary for corneal scars and opacities (including post-traumatic, post-infectious, post-surgical, and secondary to pathology).
- Phototherapeutic keratectomy (PTK) is medically necessary for epithelial membrane dystrophy.
- Phototherapeutic keratectomy (PTK) is medically necessary for irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules.
- Phototherapeutic keratectomy (PTK) is medically necessary for recurrent corneal erosions when more conservative measures (e.g., lubricants, hypertonic saline, patching, bandage contact lenses, gentle debridement of severely aberrant epithelium) have failed to halt the erosions.
- Phototherapeutic keratectomy (PTK) is medically necessary for superficial corneal dystrophy (including granular, lattice, and Reis-Bückler's dystrophy).
5 Active Policies
AMBETTER-CP.VP.13 — Preventative (Routine) Eye Examination
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
ANTHEM-CG-SURG-77 — CG-SURG-77 Refractive Surgery
Related Codes
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