H52.519 — Internal ophthalmoplegia (complete) (total), unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims must be submitted with the most appropriate diagnosis and procedure codes as of the effective date; claims submitted for services not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
- Coverage determinations require consideration of the terms of the applicable benefit plan document, applicable laws/regulations, collateral source materials including Coverage Policies, and the specific facts of the situation; each coverage request should be reviewed on its own merits (instructional requirement for documentation review).
- For anisometropia-related IOL coverage: clinical documentation demonstrating anisometropia of 2 diopters or greater and documentation that vision is uncorrectable with the use of glasses or contact lenses (i.e., refraction results and records of trial/use and intolerance or failure of corrective lenses).
Key Coverage Criteria
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: following cataract extraction.
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: trauma to the eye which has damaged the lens.
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: congenital cataract.
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: congenital aphakia.
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: lens subluxation/displacement.
- Standard monofocal intraocular lens (IOL) implant is considered medically necessary for any of the following conditions: anisometropia of 2 diopters or greater, and uncorrectable vision with the use of glasses or contact lenses.
1 Active Policy
CIGNA-0125 — Intraocular Lens Implant - (0125)
Related Codes
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