Does H59.031 require prior authorization?

No, H59.031 does not require prior authorization (high confidence). Code is covered without prior authorization.

`H59.031` — Cystoid macular edema following cataract surgery, 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.
Claims for SCODI must be submitted to the Part B MAC; bill all same‑day services for the same beneficiary/provider on the same claim.

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
SCODI (CPT 92133, 92134) is considered medically reasonable and necessary for evaluation of retinal disorders, glaucoma, and anterior segment disorders as documented in LCD L34760.
Fluorescein angiography is covered when the medical record documents medical necessity for the procedure for each eye, including relevant history, physical exam, and results of pertinent diagnostic tests.
Indocyanine green (ICG) angiography is covered when one or more of the following are documented: (1) ill-defined subretinal neovascular membrane or suspicious membrane on prior fluorescein angiography, (2) retinal pigment epithelium (RPE) does not show subretinal neovascular membrane on current fluorescein angiography, or (3) presence of subretinal hemorrhage or hemorrhagic RPE.
Diagnostic angiography (fluorescein or ICG) is covered when the claim includes a valid ICD-10-CM diagnosis code that best describes the patient's condition or the symptom prompting the test, and the ordering/referring provider's name and NPI are reported when required.
Fundus photography (CPT 92250, 92228) is covered when medical necessity is documented in the patient's medical record including relevant history, physical exam, results of pertinent tests, an interpretation/report, and retained copies of the photographs.

L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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

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L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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