CurrentAmbetter NevadaPolicy CP.VP.63

Visual Field Testing (PDF)

Defines medical necessity criteria and coding guidance for visual field testing (automated and gross perimetry) for members of Centene-affiliated health plans and Envolve Vision. Lists indications where testing is medically necessary, not medically necessary indications, CPT codes to report, and supporting ICD-10 diagnosis codes.

Policy Summary

PayerAmbetter Nevada

PolicyVisual Field Testing (PDF)

Policy CodePolicy CP.VP.63

Change TypeRevisions/annual updates (2019-2023)

Effective Date

Next Review Date

Key ActionProvider must document one of the listed medically necessary indications in the medical record to support billing of visual field CPT codes 92081-92083.

SourceLink

POLICY UPDATE CHANGES

Updated medically indicated diagnoses to include new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura.

Annual reviews in 2021 and 2022 updated medical indications to include traumatic brain injuries, hypotony, corneal opacities and lagophthalmos and added new ICD-10 codes.

17+Medically necessary indications listed

4Not medically necessary indications listed

3CPT codes listed

100+

Coverage Summary

This policy defines medical necessity criteria and coding guidance for visual field testing (automated and gross perimetry) for members of Centene-affiliated health plans and Envolve Vision. It lists the clinical indications where visual field testing is considered medically necessary, identifies not–medically necessary scenarios, and provides the CPT codes and supporting ICD-10 diagnoses to justify testing.

Modalities covered include standard automated perimetry and gross visual field assessments; the policy’s overall coverage stance is covered with criteria, meaning tests are covered when the documented medical necessity criteria and coding requirements in this policy are met.

Policy summary

Policy NumberCP.VP.63

SubjectVisual Field Testing

StatusCURRENT

Last Review2023-11

Review FrequencyAnnual

Frequency LimitNo more than 2 visual field tests per year for controlled glaucoma; testing exceeding twice per year is not medically necessary

Medical-Necessity Criteria

Medically Necessary Indications

Visual field testing is medically necessary for the following indications:

Malpositioning of the upper eyelid, including dermatochalasis, blepharochalasis, blepharoptosis, brow ptosis or injury
Glaucoma or glaucoma suspect
Diabetic and/or hypertensive retinopathy
Macular pathology, including degeneration
Functional assessment of the optic nerve in any of the following conditions: papilledema, coloboma, drusen, pallor, pseudopapilledema, Foster-Kennedy syndrome, optic nerve sheath hemorrhage, or hypoplasia

Coding

Covered CPT - Visual field examination codesCPTCovered

92081	Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent).
92082	Visual field examination, unilateral or bilateral, with interpretation and report: intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33).
92083	Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

ICD-10-CM Diagnosis Codes that Support Coverage Criteria (selected list from policy part 1)ICD-10Covered

A18.53	Tuberculous chorioretinitis
A52.15	Late syphilitic neuropathy
B58.01	Toxoplasma chorioretinitis
C69.01	Malignant neoplasm of right conjunctiva
C69.02	Malignant neoplasm of left conjunctiva
C69.11	Malignant neoplasm of right cornea
C69.12	Malignant neoplasm of left cornea
C69.21	Malignant neoplasm of right retina
C69.22	Malignant neoplasm of left retina
C69.31	Malignant neoplasm of right choroid

1–10 of 21

1/3

Medically Indicated ICD-10 Diagnoses (listed)ICD-10Covered

I65.8	Occlusion and stenosis of other precerebral arteries
I66.01	Occlusion and stenosis of right middle cerebral artery
I66.02	Occlusion and stenosis of left middle cerebral artery
I66.03	Occlusion and stenosis of bilateral middle cerebral arteries
I66.11	Occlusion and stenosis of right anterior cerebral artery
I66.12	Occlusion and stenosis of left anterior cerebral artery
I66.13	Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21	Occlusion and stenosis of right posterior cerebral artery
I66.22	Occlusion and stenosis of left posterior cerebral artery
I66.23	Occlusion and stenosis of bilateral posterior cerebral arteries

1–10 of 32

1/4

Provider Actions

Documentation Required

Document indication from medically necessary list

Provider must document one of the listed medically necessary indications in the medical record to support billing of visual field CPT codes 92081-92083.

92081
92082
92083

Denial Risk

Denial for excessive repeat testing

Claims for repeated visual field testing for a stable, diagnosed condition or more than twice per year for controlled glaucoma may be denied as not medically necessary. Note: repeated testing exceeding twice per year for controlled glaucoma is explicitly listed as not medically necessary.

Background

Visual field testing is a noninvasive, painless procedure that maps central and peripheral vision and produces a printout of light thresholds across the visual field; patterns of loss help localize pathology within the visual pathway. The policy describes medical necessity requirements for when such testing should be performed.

The policy notes that standard white-on-white automated perimetry is the most commonly performed modality, with the Swedish Interactive Threshold Algorithm (SITA) largely replacing full-threshold strategies. It also references alternate modalities — frequency-doubling technology (FDT) and Matrix perimetry, and short-wavelength automated perimetry — summarizing relative performance characteristics (sensitivity/specificity and practical limitations). Gross confrontation testing and computerized screening field assessments are described as part of general ophthalmologic services and should not be reported separately.

Evidence and guidance referenced in this policy include American Academy of Ophthalmology (AAO) perimetry reports and Preferred Practice Pattern guidelines (reports spanning 2001–2020) and educational resources such as the Mayfield Clinic visual field test overview.

Revision History

11/2023revisedLatest

Updated medically indicated diagnoses to include new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura. Detail: Listed current ICD-10 codes included.

11/2022clarified

Annual reviews in 2021 and 2022 updated medical indications to include traumatic brain injuries, hypotony, corneal opacities and lagophthalmos and added new ICD-10 codes. Detail: Revision history lines included in the document; no explicit clinical statement changes in this extract.

12/2019 - 12/2020revised

Medically Indicated Diagnoses for Visual Field Testing (ICD-10 list)

Visual field testing is considered medically indicated when performed for members with any one of the following ICD-10 diagnoses (any single listed diagnosis supports testing):

Medically Indicated ICD-10 Diagnoses

I65.8 - Occlusion and stenosis of other precerebral arteries
I66.01 - Occlusion and stenosis of right middle cerebral artery
I66.02 - Occlusion and stenosis of left middle cerebral artery
I66.03 - Occlusion and stenosis of bilateral middle cerebral arteries
I66.11 - Occlusion and stenosis of right anterior cerebral artery
I66.12 - Occlusion and stenosis of left anterior cerebral artery
I66.13 - Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21 - Occlusion and stenosis of right posterior cerebral artery
I66.22 - Occlusion and stenosis of left posterior cerebral artery
I66.23 - Occlusion and stenosis of bilateral posterior cerebral arteries
I66.3 - Occlusion and stenosis of cerebellar arteries
I67.1 - Cerebral aneurysm, nonruptured
I67.2 - Cerebral atherosclerosis
I67.4 - Hypertensive encephalopathy
I67.5 - Moyamoya disease
I67.6 - Nonpyogenic thrombosis of intracranial nervous system
I67.81 - Acute cerebrovascular insufficiency
I67.82 - Cerebral ischemia
I67.83 - Posterior reversible encephalopathy syndrome
I67.841 - Reversible cerebrovascular vasoconstriction syndrome
I67.850 - Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
I68.0 - Cerebral amyloid angiopathy
M31.5 - Giant cell arteritis with polymyalgia rheumatica
M31.6 - Other giant cell arteritis
Q10.0 - Congenital ptosis
Q14.0 - Congenital malformation of vitreous humor
Q14.1 - Congenital malformation of retina
Q14.2 - Congenital malformation of optic disc
Q14.3 - Congenital malformation of choroid
Q15.0 - Congenital glaucoma
Q85.01 - Neurofibromatosis, type 1
Q85.03 - Schwannomatosis
S04.011A/S04.011D/S04.011S - Injury of optic nerve, right eye (initial, subsequent, sequela)
S04.012A/S04.012D/S04.012S - Injury of optic nerve, left eye (initial, subsequent, sequela)
S04.02XA/S04.02XD/S04.02XS - Injury of optic chiasm (initial, subsequent, sequela)
S04.031A/S04.031D/S04.031S - Injury of optic tract and pathways, right eye (initial, subsequent, sequela)
S04.032A/S04.032D/S04.032S - Injury of optic tract and pathways, left eye (initial, subsequent, sequela)
S04.041A/S04.041D/S04.041S - Injury of visual cortex, right eye (initial, subsequent, sequela)
S04.042A/S04.042D/S04.042S - Injury of visual cortex, left eye (initial, subsequent, sequela)
Multiple additional listed trauma, neurologic, retinal, optic nerve, and ocular diagnosis codes (e.g., contusions, concussions, intracranial hemorrhage, retinal detachments, retinal vascular occlusions, macular pathology, optic neuropathies, etc.) as enumerated in the policy ICD-10 list
See policy ICD-10 code list for full supporting codes