H53.489 — Generalized contraction of visual field, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
- Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.
Key Coverage Criteria
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
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11 Active Policies
L33766 — Visual Field Examination
J09
A57637 — Billing and Coding: Visual Field Examination
J09
AETNA-CPB-0344 — Optic Nerve and Retinal Imaging Methods
AETNA-CPB-0489 — Orthoptic Vision Therapy
ANTHEM-CG-SURG-03 — CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
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