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Return Date?
Level of Service
Est. Comprehensive - EYE
Est. Intermediate - EYE
HVF
OCT RNFL
Gonio
OCT Macula
Fundus Photos
Pachymetry
External Photos
Depressed DFE - Initial
IOL Master
Depressed DFE - Subsequent
A-Scan
E/M Modifiers
• • •
Dilate and irrigate
• • •
Punctal Plugs
• • •
FB removal - Conj, external eye
• • •
Probe and Irrigate
• • •
FB removal - Cornea
• • •
FB removal - embedded, subconj, sclera
• • •
Bandage contact lens
• • •
Corneal Scrapping
• • •
AC Paracentesis
• • •
Intravitreal injection
• • •
AC Injection
• • •
Subconj injection
• • •
Chalazion excision
• • •
Epiliation
• • •
Chalazion excision, both lids, one eye
• • •
Chalazion excision, multiple, same lid
• • •
Eyelid lesion removal
• • •
Drainage of conjunctiva/eyelid cyst
• • •
Drainage of abscess
• • •
Cataract Surgery
• • •
Complicated Cataract Surgery
• • •
Pterygium excision with graft
• • •
Glaucoma drainage implant
• • •
SLT/ALT
• • •
LPI
• • •
YAG Capsulotomy
• • •
Laser Iridoplasty
• • •
Focal Laser
• • •
PRP
• • •
Other
Other

Prior Authorization Request Medical Form

Pediatrician

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Published: Jan. 4, 2016, 6:50 p.m.
Doctor: Dr. History Physical
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