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. 

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.