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Cataract surgery prior authorization to correct blurred vision

Is Preauth Required? Evidence indicates that preauthorization may be required for cataract surgery to treat blur vision if one of the following is true: confirmation that the cataract is causing visual impairment or other ocular or systemic conditions, unacceptable glare, polyopia, or reduced quality of vision, clinically significant anisometropia in the presence of a cataract, lens opacity interferes with optimal diagnosis or management of posterior segment conditions, lens causes inflammation or secondary glaucoma (phacolysis, phaco-anaphylaxis) or worsening angle closure (phacomorphic glaucoma) due to increase in size of the crystalline lens.

Will the claim be denied? Cataract surgery may be considered medically reasonable and necessary to treat blur vision if the impairment is near and determined by a careful refraction under standard testing conditions, and the lens opacity interferes with optimal diagnosis or management of posterior segment conditions. If these criteria are not met, the claim may be denied.

When is the following treatment medically necessary for the condition specified? Cataract surgery is medically necessary for the condition of blurred vision when it is determined that the blurriness is caused by a cataract. Cataracts cause a clouding of the lens, which can cause vision to become blurry or dim. The patient's record should include a comprehensive ophthalmologic exam or its equivalent components, specialized ophthalmic studies to establish or exclude medical necessity, and a statement that the patient understands the risks, benefits, and alternatives of the surgery and that the surgery is being done to address the medical condition of blurred vision.

What would make the following treatment considered medically necessary? Cataract surgery is considered medically necessary to treat blurred vision when the preoperative ophthalmologic evaluation indicates that the blurred vision is caused by cataracts and when the patient has been informed of the risks, benefits, and alternatives to the surgery and has indicated their desire to proceed with the surgery.

What are the relevant codes for the treatment? Cataract surgery is coded with CPT code 66984. Conditions related to the surgery such as blur vision would typically be coded with the ICD-10-CM codes included in Group 1 of this context, such as E08.36 (Diabetes mellitus due to underlying condition with diabetic cataract), E09.36 (Drug or chemical induced diabetes mellitus with diabetic cataract), E10.36 (Type 1 diabetes mellitus with diabetic cataract), E11.36 (Type 2 diabetes mellitus with diabetic cataract), E13.36 (Other specified diabetes mellitus with diabetic cataract), H20.21 (Lens-induced iridocyclitis, right eye), H20.22 (Lens-induced iridocyclitis, left eye), H20.23 (Lens-induced iridocyclitis, bilateral), H21.221 (Degeneration of ciliary body, right eye), H21.222 (Degeneration of ciliary body, left eye), H21.223 (Degeneration of ciliary body, bilateral), H21.261 (Iris atrophy (essential) (progressive), right eye), H21.262 (I




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