Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

New methods are being developed for looking at the retina – the back of the eye. These new examinations may be very helpful in certain eye diseases. Examples of these new examinations are:

·         Confocal Laser Scanning Tomography,

·         Laser Scanning Polarimetry,

·         Optical Coherence Tomography (OCT) and

·         Stereophotogrammetry.

Candidates for these tests would be people with:

·         Glaucoma, or

·         Presumed glaucoma, or

·         Diseases or injuries that directly affect the retina and optic nerve.

Methods for evaluating the retina and optic nerve:

1.    Optic nerve and retinal imaging methods include confocal laser scanning tomography, nerve fiber layer testing or analysis (confocal laser scanning tomography with polarimetry), stereo photogrammetry, and optical coherence tomography (OCT). These are considered medically necessary for documenting the appearance of the optic nerve head and retina in:

a.    Persons with Glaucoma

b.    Persons with presumed Glaucoma and

c.    Persons with diseases that directly affect the retina and optic nerve

2.    Ophthalmoscopy, extended, with retinal drawing

a.    retinal detachment

b.    melanoma

c.    retinal holes/tears

d.    lattice degeneration

e.    vascular lesions and

f.     neoplasms

Codes Used In This BI:

92132             Scanning computerized ophthalmic diagnostic imaging, anterior segment, w/inter & rpt, unilateral or bilateral

92133             Scanning computerized ophthalmic diagnostic imaging, posterior segment, w/inter & rpt, unilateral or bilateral; optic nerve

92134             Scanning computerized ophthalmic diagnostic imaging, posterior segment, w/inter & rpt, unilateral or bilateral; retina

0604T             Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; initial device provision, set-up and patient education on use of equipment (new code 7/1/2020): E/I

0605T             Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days (new code 7/1/2020): E/I

0606T             Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days (new code 7/1/2020): E/I

Optic nerve and retinal imaging is not considered medically necessary for screening. The standard methods of screening for glaucoma include ophthalmoscopy, tonometry, perimetry, and gonioscopy. These procedures are considered part of the comprehensive ophthalmologic examination.

Home OCT (patient –initiated) and associated remote monitoring is considered experimental/investigational and not covered. 

Recently, other methods of measuring the optic disc and the nerve fiber layer have been developed in an attempt to create more accurate and reproducible methods of screening, detecting, and following structural parameters related to glaucoma. These methods include the following:

Confocal Laser Scanning Tomography

The confocal laser scanning tomographic ophthalmoscope is a device that scans layers of the retina to make quantitative measurements of the surface features of the optic nerve head and fundus. It has been used as an alternative to standard ophthalmologic methods of evaluating the optic nerve head and fundus in patients with glaucoma, papilledema, and other disorders affecting the retina. Other terms for confocal laser scanning tomography include: laser scanning topography, confocal scanning laser topography, electro-optic fundus imaging and scanning laser polarimetry. Types of confocal laser scanning ophthalmoscopes include:

·        Heidelberg Laser Tomographic Scanner or Heidelberg Retina Tomograph (HRT) (Heidelberg Engineering, Dossenheim, Germany),

·        TopSS Topographic Scanning System (Laser Diagnostic Technologies, San Diego, CA); and the

·        Zeiss™ Confocal Laser Scanning Ophthalmoscope. (Zeiss Humphrey Systems, Dublin, CA).

Nerve Fiber Layer Testing or Analysis (Laser Scanning Polarimetry)

Thinning of the nerve fiber layer is associated with glaucomatous damage and has been shown to be correlated with visual field loss. The GDx Nerve Fiber Analysis System (Laser Diagnostic Technologies, Inc., San Diego, CA) is a confocal laser scanning ophthalmoscope with an integrated polarimeter. Instead of measuring topography, or height of the retina, like other confocal laser scanners, GDx measures the thickness of the retinal nerve fiber layer and then analyzes the results and compares them to a database of normative values.

Optical Coherence Tomography

Optical coherence tomography (OCT) (e.g., Humphrey OCT Scanner (Zeiss Humphrey, Dublin, CA)) has also been used for screening, diagnosis, and management of glaucoma and other retinal diseases. In OCT, low coherence near-infrared light is split into a probe and a reference beam. The probe beam is directed at the retina while the reference beam is sent to a moving reference mirror (AHFMR, 2003). The probe light beam is reflected from tissues according to their distance, thickness, and refractive index, and is then combined with the beam reflected from the moving reference mirror. When the path lengths of the two light beams coincide (known as constructive interference) this provides a measure of the depth and reflectivity of the tissue that is analogous to an ultrasound A scan at a single point. A computer then corrects for axial eye movement artifacts and constructs a two dimensional B mode image from successive longitudinal scans in the transverse direction. A map of the tissue is then generated based on the different reflective properties of its components, resulting in a real-time cross-sectional histological view of the tissue.

This is helpful for diagnosing retinal problems such as macular holes, macular edema, macular traction, etc.  Many conditions that change the retinal contour can be more fully evaluated by this technology since it provides an optical cross-section of living tissue.

Another capability of this technology is the ability to measure the retinal nerve fiber layer thickness as a way to diagnose and follow-up glaucoma patients.  One of the most difficult aspects of ascertaining glaucoma progression has been the absence of an objective measurement of nerve fiber layer loss in glaucoma.  Physicians have relied on subjective tests (visual fields) that lag far behind significant nerve fiber layer loss before becoming abnormal

Stereophotogrammetry

Stereophotogrammetry, (Glaucoma-Scope (OIS, Sacramento, CA)) measures the dimensions of the optic disc in three-dimensional space using stereophotography. Stereophotographs are taken from two camera positions with parallel optical axes. Stereoanalysis of these photographs are used to determine the three-dimensional characteristics of the optic nerve head, and for following glaucomatous change of the optic nerve head over time. Stereoplotters and digital computer processing of scanned images have been used in an attempt to provide more quantitative, objective, and reproducible methods of measuring optic nerve disc changes.

1.    Lee DA, Nakia ML, Juzych MS, et al. Optic nerve head and retinal nerve fiber layer analysis. Opthalmic Technology Assessment. A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel. Ophthalmology. 1999; 106:1414-1424. Available at: http://www.aao.org/aao/education/library/ota/index.cfm .

2.    Laser Diagnostic Technologies, Inc. (LDT). GDx Nerve Fiber Analyzer. San Diego, CA: LDT; 1999. Available at: http://www.laserdiagnostic.com/produc0.htm. Accessed November 1, 1999.

3.    Fong DS, Aiello L, Gardner TW, et al. Retinopathy in diabetes. American Academy of Diabetes Position Statements. Diabetes Care. 2004; 27(Suppl 1):S84-S87.

4.    American Academy of Ophthalmology (AAO). Primary open-angle glaucoma. Preferred Practice Pattern. Limited Revision. San Francisco, CA: AAO; November 2003. Available at: http://www.aao.org/aao/education/library/ppp/index.cfm .

5.    American Academy of Ophthalmology (AAO). Primary open-angle glaucoma suspect. Preferred Practice Pattern. San Francisco, CA: AAO; September 2002. Available at: http://www.aao.org/aao/education/library/ppp/index.cfm .

6.    American Academy of Ophthalmology (AAO). Primary angle-closure. Preferred Practice Pattern. San Francisco, CA: AAO; September 2000. Available at: http://www.aao.org/aao/education/library/ppp/index.cfm 

7.    American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; September 2003.

8.    American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; September 2003.

9.    American Academy of Ophthalmology (AAO). Posterior vitreous detachment, retinal breaks, and lattice degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; September 2003. Available at: http://www.aao.org/education/library/ppp/pvd_new.cfm .

10. Wu L. Neovascularization, choroidal. eMedicine Ophthalmology Topic 534. Omaha, NE: eMedicine.com; updated January 27, 2005. Available at: http://www.emedicine.com/oph/topic534.htm.

11. American Academy of Ophthalmology (AAO). Idiopathic macular hole. Preferred Practice Pattern. San Francisco, CA; AAO; September 2003. Available at: http://www.aao.org/education/library/ppp/mh_new.cfm .

12. Valero SO, Atebara NH. Macular hole. eMedicine Ophthalmology Topic 401. Omaha, NE: eMedicine.com; updated October 8, 2001. Available at: http://www.emedicine.com/oph/topic401.htm

13. American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; September 2003. Available at: http://www.aao.org/education/library/ppp/amd_new.cfm .

14. American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; September 2003. Available at: http://www.aao.org/education/library/ppp/dr_new.cfm.

15. Khan BU, Lam W. Macular edema, diabetic. eMedicine Ophthalmology Topic 399. Omaha, NE: eMedicine.com; updated August 4, 2004. Available at: http://www.emedicine.com/oph/topic399.htm .

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.