Does Q12.3 require prior authorization?

No, Q12.3 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Q12.3` — Congenital aphakia

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The diagnosis code that justifies medical need must be included on the claim for refractive lenses and related items.
Final Rule 1713 items require a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes; claims lacking face-to-face and WOPD per the LCD will be denied and items delivered before receipt of a WOPD will be denied.
For anti-reflective coating (V2750), tints (V2744,V2745), oversized lenses (V2780), and polycarbonate/Trivex (V2784) when used for medical necessity (and V2784 for monocular vision), the KX modifier must be added and supporting medical necessity documentation must be available upon request; if criteria are not met the GA or GZ modifier must be used (GA if a valid ABN is on file, GZ if not).
Claim lines for anti-reflective coating, tints, oversized lenses or polycarbonate/Trivex billed without a KX, GA or GZ modifier will be rejected as missing information.

Refractive lenses are covered when used to restore vision normally provided by the natural lens in individuals who lack the organic lens because of surgical removal or congenital absence.
Coverage of refractive lenses applies even if the surgical removal of the natural lens occurred before Medicare entitlement.
Speech-language pathology (SLP) services for treatment or evaluation of communication disorders when determined reasonable and necessary per LCD L35070.
Selection and prescription of speech-generating devices should be billed with CPT code 92607.
Adaptation and training for speech-generating devices should be billed with CPT code 92609.
Report group therapy with CPT code 92508 when patients are not receiving direct one-on-one contact and are supervised by the therapist.

A59805 — Billing and Coding: Cataract Surgery

J05

L34615 — Visual Fields

J05

L39905 — Cataract Surgery

J05

A57483 — Billing and Coding: Visual Fields

J05

A56544 — Billing and Coding: Cataract Extraction

Ask Verity about documentation requirements, denial risks, or coverage in your state.