CurrentAmbetter NevadaPolicy CP.VP.28

Fluorescein Angiography

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.VP.28 alerts

Get alerted when Policy CP.VP.28 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity criteria and coding guidance for intravenous fluorescein angiography (retinal/choroidal angiography) for members of Ambetter Nevada / Centene-affiliated health plans and Envolve Vision.

Policy Summary

PayerAmbetter Nevada

PolicyFluorescein Angiography

Policy CodePolicy CP.VP.28

Change TypeNo material change

Effective Date

Last ReviewNov 20, 2023

Next Review Date

Key ActionWhen billing for fluorescein angiography, submit CPT 92235 with one of the policy-listed ICD-10 diagnoses (including laterality) to support medical necessity.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAmbetter NevadaPolicy CP.VP.28

Fluorescein Angiography

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.VP.28 alerts

Get alerted when Policy CP.VP.28 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Nevada

PolicyFluorescein Angiography

Policy CodePolicy CP.VP.28

Change TypeNo material change

Effective Date

Last ReviewNov 20, 2023

Next Review Date

Key ActionWhen billing for fluorescein angiography, submit CPT 92235 with one of the policy-listed ICD-10 diagnoses (including laterality) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92235Primary CPT code referenced

E10–E13, H15–H35, etc.ICD-10 root blocks

6-12 moSurveillance interval

YesLaterality specified

12/2019Original approval

5+References

Medical Necessity & Coverage Criteria

Medically Necessary Indications

Fluorescein angiography is considered medically necessary for the following indications:

Initial retinal abnormality indications: Initial evaluation of a patient with abnormal findings of the fundus/retina on ophthalmoscopy, including choroidal neovascular membranes; lesions of the retinal pigment epithelium (serous detachment, tears/rips, hemorrhagic detachment); fibrovascular disciform scar; vitreous hemorrhage presenting with sudden loss of vision; drusen; retinopathy.

(From policy I.A)

Symptomatic presentation: Evaluation of a patient presenting with symptoms such as sudden (especially central) vision loss, blurred vision, or visual distortion that may suggest subretinal neovascularization and corresponding abnormal ophthalmoscopic findings.

(From policy I.B)

Diabetic retinopathy: Evaluation of patients with nonproliferative (background) or proliferative diabetic retinopathy without macular edema. Frequency is determined by disease progression and treatment; may be performed on the treated eye at 6 weeks post‑treatment and as often as every 8–12 weeks to assist management.

(From policy I.C and subpoints a-b)

Known retinal/macular disorders: Evaluation of patients with known retinal or macular disorders, including age-related macular degeneration (nonexudative surveillance every 6–12 months; exudative follow-up per schedule), macular edema (including cystoid macular edema), central or branch retinal vein occlusion, tumors of the choroid and retina, and retinal arterial disease.

(From policy I.E and chunk 3 details)

Other evaluations: Evaluation of patients with chorioretinitis, chorioretinal scars, choroidal degeneration/dystrophies, hemorrhage, rupture or detachment; ocular tumors; visual loss related to systemic disease; and optic disc disease.

(From policy I.D and I.F)

Diagnosis-based coverage

Covered when an applicable diagnosis from the listed ICD-10 codes is submitted

Diagnosis from list: Fluorescein angiography is supported when the claim includes one of the ICD-10 diagnoses enumerated in this policy (examples include diabetic retinopathy codes E10–E13; retinal, choroidal, inflammatory and vascular codes H15–H35; G45.3; and others listed in the ICD-10 sections).n>=1

Providers should submit the applicable ICD-10 diagnosis (including laterality when specified) from the policy's listed codes to support medical necessity.

Medically indicated uses

Covered when the procedure is used to evaluate or manage the following ocular diagnoses (ICD-10 codes listed):

Medically indicated diagnoses: Fluorescein angiography is considered medically indicated for evaluation or management of a broad set of retinal and posterior segment conditions as enumerated by the ICD-10 codes in the policy (examples include retinopathy of prematurity stages, nonexudative and exudative age-related macular degeneration, macular cyst/hole/pseudohole, cystoid macular degeneration/edema, drusen, macular puckering, toxic maculopathy, secondary pigmentary/vitreoretinal degeneration and dystrophies, retinal hemorrhage, central serous chorioretinopathy, serous/hemorrhagic RPE detachments, retinal edema/ischemia, sickle-cell retinopathy, vitreous hemorrhage, vitreomacular adhesion, degenerative myopia with CNV, optic nerve/optic disc disorders, sudden vision loss, post‑cataract cystoid macular edema, congenital posterior segment malformations, and abnormal ERG).

See full ICD-10 lists in policy chunks 36–45 for complete code set.

Inclusion or exclusion of codes in this clinical policy does not by itself guarantee coverage. Providers must reference current professional coding guidance and plan-specific instructions prior to claim submission. The policy lists CPT and ICD-10 codes for informational purposes; verify applicable coding and billing rules before performing or submitting claims for services such as CPT 92235.

The document segment provided does not specify any explicit exclusions for fluorescein angiography. Absence of an exclusion in this policy extract does not override plan terms—review the full policy and member coverage documents for any limitations that may apply.

Where applicable, state Medicaid coverage provisions take precedence over this clinical policy. If state Medicaid rules conflict with the policy language, follow the state Medicaid manual and related regulations for coverage determinations and claims processing.

This section is a summary placeholder referencing the clinical policy for intravenous fluorescein angiography (Reference Number: CP.VP.28). Consult the full policy for detailed medical necessity criteria, ICD-10 code lists, documentation expectations, and prior authorization requirements before authorizing or billing this procedure.

Procedure and Diagnosis Coding

Covered CPT CodesCPTCovered

92235

Fluorescein angiography (includes multi-frame imaging) with interpretation and report

ICD-10 Diagnosis Codes that Support Coverage Criteria (selected)ICD-10

E10.3523	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3531	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E10.3533	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3541	Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E10.3542	Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E10.3543	Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E10.3551	Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E10.3552	Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E10.3553	Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

1–10 of 108

1/11

Billing, Documentation & Provider Requirements

Billing Rule

Procedure coding requirement

When billing for fluorescein angiography ensure CPT 92235 (fluorescein angiography with interpretation and report) is used and is supported by an appropriate ICD-10 diagnosis from the policy's listed codes. Claims lacking a supported diagnosis or appropriate procedure coding may be denied.

Required CPT: 92235 (fluorescein angiography with interpretation and report)
Include an ICD-10 diagnosis code from the policy's supported list when submitting claims

Prior Authorization

Prior authorization / code linkage

Fluorescein angiography (CPT 92235) should be accompanied on the prior authorization or claim by one of the ICD-10 diagnoses listed in this clinical policy to support medical necessity. If the submitted diagnosis is not among the listed codes, authorization or payment may be declined.

Clinical Background

Intravenous fluorescein angiography is performed by systemic injection of sodium fluorescein with serial photographic imaging using blue-light excitation (approximately 490 nm) to evaluate retinal and choroidal circulation. The technique delineates leaking capillaries, neovascularization, microaneurysms and retinal pigment epithelium defects and creates a permanent photographic or electronic record. Typical procedure workflow includes baseline color and red‑free images prior to injection, a bolus injection with rapid serial imaging beginning about 10 seconds after injection, and delayed images at approximately 5–10 minutes (occasionally up to 15 minutes) to document late-phase findings.

Definitions & Key Terms

Fluorescein angiography

DefinitionIntravenous injection of sodium fluorescein with serial photographic imaging using blue-light excitation (approx. 490 nm) to evaluate retinal and choroidal circulation.

Technique — injectionTypical bolus: 2–5 cc of sodium fluorescein given intravenously over ~6 seconds, followed by rapid serial imaging beginning ~10 seconds after injection.

Technique — imagingBaseline color and black-and-white red-free images are taken prior to injection; photos are obtained about once per second for ~20 seconds then less frequently; delayed images at 5 and 10 minutes (sometimes 15 minutes).

Optical filteringA blue-light excitation (~490 nm) is used and a filter records fluorescent yellow-green emission (~530 nm); red-free (green) filtering increases fundus contrast.

Diabetic retinopathy

Scope of codes

Policy Summary

PayerAmbetter Nevada

PolicyFluorescein Angiography

Policy CodePolicy CP.VP.28

Change TypeNo material change

Effective Date

Last ReviewNov 20, 2023

Next Review Date

Key ActionWhen billing for fluorescein angiography, submit CPT 92235 with one of the policy-listed ICD-10 diagnoses (including laterality) to support medical necessity.

SourceLink

On This Page

Link CPT 92235 to an ICD-10 code from the policy's supported diagnosis list
Claims with diagnoses not listed may be subject to denial or request for additional information

Prior Authorization

Prior authorization verification

Prior authorization requirements are governed by the Health Plan's administrative policies and the member's coverage documents. Verify prior authorization requirements, submission process and effective dates with the plan before performing the service.

Verify PA requirements and submission instructions with Ambetter Nevada/Health Plan
Check member coverage documents and plan-level administrative policies for any exceptions

Documentation Required

Imaging documentation

Obtain and retain permanent photographic or electronic imaging records. Baseline color and red-free (black-and-white) images must be taken prior to fluorescein injection, and timed sequence images obtained during and after injection per standard technique to document findings.

Baseline color and red-free filtered images taken prior to injection
Timed sequence images (approximately every second initially, delayed images at ~5 and 10 minutes; some clinicians obtain 15-minute images)
Maintain a permanent photographic or electronic record to support the medical necessity of the procedure

Documentation Required

Documentation & claim submission

Providers must document the applicable ICD-10 diagnosis (including laterality where appropriate) from the policy's listed codes and include documentation that supports medical necessity in the medical record and on submitted claims. Follow plan coverage documents and applicable state and federal requirements when submitting claims.

Document ICD-10 diagnosis code with laterality when applicable
Include clinical findings from ophthalmoscopy/exam and reason for fluorescein angiography in the record
Ensure documentation aligns with Health Plan coverage rules and state/federal requirements

Denial Risk

Denial risk sources

Claims submitted without a supported ICD-10 diagnosis from the policy list, without appropriate procedure coding (CPT 92235), or without adequate documentation (imaging and clinical justification) may be denied. Coverage is subject to all terms, conditions, exclusions and limitations in the member's coverage documents and applicable legal/regulatory requirements.

Denials may result from missing/unsupported diagnosis codes, incorrect CPT coding, or lack of supporting documentation
Coverage determinations remain subject to the member's benefit plan, exclusions, and applicable state/federal rules

Multiple ICD-10 codes for type 1 (E10.*), type 2 (E11.*) and other specified diabetes (E13.*) are listed, covering mild, moderate, severe nonproliferative and proliferative diabetic retinopathy with and without macular edema.

Examples (type 1)E10.3291 / E10.3292 / E10.3293 (mild NPDR without macular edema, right/left/bilateral); E10.3311 / E10.3312 / E10.3313 (moderate NPDR with macular edema, right/left/bilateral).

Examples (type 2)E11.3311 / E11.3312 / E11.3313 (moderate NPDR with macular edema, right/left/bilateral); E11.3391 / E11.3392 (moderate NPDR without macular edema, right/left).

Coverage implicationFluorescein angiography is supported when claims include these diabetic retinopathy ICD-10 codes and documentation justifies the procedure for evaluation/management.

Retinal vascular occlusion

Included occlusion codesPolicy lists ICD-10 codes for retinal arterial and venous occlusions under H34.* and related subcodes (e.g., H34.01–H34.03 transient retinal artery occlusion; H34.11–H34.13 central retinal artery occlusion; H34.8110–H34.8132 central retinal vein occlusion variants).

Branch/tributary codesTributary (branch) retinal vein occlusion codes are included (H34.8310–H34.8332) covering right/left/bilateral and macular edema/neovascularization status.

Venous engorgement and related findingsCodes for venous engorgement (H34.821–H34.823) and other retinal vascular appearance changes (H35.011 etc.) are enumerated as relevant diagnoses.

Medically indicated diagnoses

General ruleFluorescein angiography is considered medically indicated when used to evaluate or manage the ICD-10 diagnoses enumerated in the policy; include one of the listed diagnosis codes on the claim with supporting documentation.

Representative diagnosis groupsListed diagnoses include diabetic retinopathies (E10–E13), retinal vascular occlusions (H34.*), retinal inflammatory/chorioretinal disorders (H30–H33), age-related macular degeneration variants (H35.31x–H35.32x), and retinopathy of prematurity (H35.13x–H35.17x).

Side-specific examplesMany of the enumerated codes are side-specific (right/left/bilateral) across the diagnosis list — e.g., H33.121 (parasitic cyst of retina, right eye) and H35.3211 (exudative AMD, right eye with active CNV).

Use for managementThe listed diagnoses support angiography for initial evaluation, symptomatic sudden vision loss, monitoring post-treatment, and guiding interventions such as laser for neovascularization or CNV.