Ambetter Nevada Fluorescein Angiography Coverage

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

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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