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Prior Authorization Request Form

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Enter the primary diagnosis code, based on available protocol list

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1.  Margin reflex distance 1 (MRD(1)) of 2 millimeters or less
2.  Superior visual field loss of at least 12 degrees or 24%

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Selection of Expedited status requires submission of a letter of medical need, signed by MD or OD, describing in detail how patient will be harmed by Standard processing time.

Please upload all relevant information to support the medical necessity of this request as outlined in the Clinical Protocol, e.g., progress notes, images outlining clinical treatment plan to date, testing interpretation, and any other substantiating information.