P07.24 — Extreme immaturity of newborn, gestational age 25 completed weeks
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Detailed drawing(s) of views of the patient's retina(s) and any defects documented in the medical record.
- Record of the examination method used (direct vs indirect; contact lens, H‑ruby lens, or 90‑diopter lens), which eye(s) were examined, and identity/licensure of the performing eye care provider.
- Detailed retinal drawing (disc, macula or periphery) accompanied by an interpretation and report.
- Drawing must be anatomically specific to the patient, clearly labeled, and of sufficient size (no less than 3–4 inches in diameter).
Key Coverage Criteria
- Infants undergoing treatment and/or monitoring of retinopathy of prematurity.
- Histoplasmosis affecting the eye requiring detailed ophthalmoscopic evaluation.
- Choroidal neoplasms requiring extended retinal imaging or evaluation.
- Glaucoma when extended ophthalmoscopy is needed for assessment or monitoring.
- Optic nerve pathology requiring detailed ophthalmoscopic examination.
- Diabetic retinopathy requiring extended ophthalmoscopy for diagnosis or monitoring.
1 Active Policy
AMBETTER-CP.VP.26 — Extended Ophthalmoscopy
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