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12437 Results

Keratoprosthesis

Service Code
65770 (CPT) Keratoprosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radial keratotomy

Service Code
65771 (CPT) Radial keratotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Corneal relaxing incision for correction of surgically induced astigmatism

Service Code
65772 (CPT) Corneal relaxing incision for correction of surgically induced astigmatism
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Corneal wedge resection for correction of surgically induced astigmatism

Service Code
65775 (CPT) Corneal wedge resection for correction of surgically induced astigmatism
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

1T-2, Special Ophthalmological Services

Service Code
65778 (CPT) Placement of amniotic membrane on the ocular surface; without sutures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Length of Stay

beneficiaries are each limited to 2 times per year.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

Placement of amniotic membrane on the ocular surface; single layer, sutured

Service Code
65779 (CPT) Placement of amniotic membrane on the ocular surface; single layer, sutured
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ocular surface reconstruction; amniotic membrane transplantation, multiple layers

Service Code
65780 (CPT) Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor)

Service Code
65781 (CPT) Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft)

Service Code
65782 (CPT) Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Implantation of intrastromal corneal ring segments

Service Code
65785 (CPT) Implantation of intrastromal corneal ring segments
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous

Service Code
65800 (CPT) Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection

Service Code
65810 (CPT) Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection

Service Code
65815 (CPT) Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Goniotomy

Service Code
65820 (CPT) Goniotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Trabeculotomy ab externo

Service Code
65850 (CPT) Trabeculotomy ab externo
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Trabeculoplasty by laser surgery

Service Code
65855 (CPT) Trabeculoplasty by laser surgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Severing adhesions of anterior segment, laser technique (separate procedure)

Service Code
65860 (CPT) Severing adhesions of anterior segment, laser technique (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae

Service Code
65865 (CPT) Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae

Service Code
65870 (CPT) Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae

Service Code
65875 (CPT) Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required