Does Z01.021 require prior authorization?

No, Z01.021 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Z01.021` — Encounter for examination of eyes and vision following failed vision screening with abnormal findings

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Record visual acuity with current correction (power documented) at distance and, when appropriate, at near; include refraction when indicated.
Document visual fields by confrontation or automated screening devices (non-threshold).
Document external examination findings: eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent facial features.
Document pupillary function: size, light response, and assessment for relative afferent pupillary defect.

Initial optical coherence tomography of the posterior segment of the eye is consideredmedically necessaryfor any of the following:
To establish a diagnosis of a condition affecting the optic nerve or retina (including, but not limited to glaucoma, optic neuropathy, macular degeneration, diabetic retinopathy, macular edema, atrophy associated with degenerative retinal diseases),when a clinical diagnosis is uncertain;or
To establish a baseline prior to treatment of a condition affecting the optic nerve or retina.
Repeat optical coherence tomography of the posterior segment of the eye is consideredmedically necessaryto monitor a condition affecting the optic nerve or retina when there is documentation that changes detected on imaging (based on the anticipated clinical progression of the underlying disease) are likely to impact management; for example:
To monitor for disease progression in individuals with glaucoma;or
To manage retinal conditions undergoing active treatment (such as wet age-related macular degeneration, choroidal neovascularization, macular edema, diabetic retinopathy [proliferative and nonproliferative], branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema) (that is: used for therapeutic decision making based on the individual’s treatment protocol and clinical response as documented in the medical record);or

AMBETTER-CP.VP.13 — Preventative (Routine) Eye Examination

ANTHEM-CG-MED-85 — CG-MED-85 Posterior Segment Optical Coherence Tomography

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