CurrentAmbetter NevadaPolicy CP.VP.31

Gonioscopy (Clinical Policy)

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Medical necessity criteria and coding guidance for performing gonioscopy for health plans affiliated with Centene/Envolve Vision; intended for providers submitting claims and requesting coverage.

Policy Summary

PayerAmbetter Nevada

PolicyGonioscopy (Clinical Policy)

Policy CodePolicy CP.VP.31

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionVerify coverage and prior authorization requirements for CPT 92020 with the plan prior to submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10explicit clinical indications listed as medically necessary

1referenced CPT procedure code

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CurrentAmbetter NevadaPolicy CP.VP.31

Gonioscopy (Clinical Policy)

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.VP.31 alerts

Get alerted when Policy CP.VP.31 changes without checking for updates manually.

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Medical necessity criteria and coding guidance for performing gonioscopy for health plans affiliated with Centene/Envolve Vision; intended for providers submitting claims and requesting coverage.

Policy Summary

PayerAmbetter Nevada

PolicyGonioscopy (Clinical Policy)

Policy CodePolicy CP.VP.31

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionVerify coverage and prior authorization requirements for CPT 92020 with the plan prior to submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10explicit clinical indications listed as medically necessary

1referenced CPT procedure code

multipleICD-10 codes listed to support coverage

12/2019Original approval

Coverage / Medical Necessity Criteria

Medically Necessary Indications

Gonioscopy is medically necessary when ANY of the following indications are present:

Indications for gonioscopy: A. Glaucoma; B. Glaucoma suspect; C. Ocular trauma; D. Hyphema; E. Hypotony; F. Occlusive disorders; G. Diabetic retinopathy; H. Rubeosis; I. Intraocular foreign body; or J. Subluxated or dislocated lens.

List taken verbatim from policy.

General policy guidance — Policy guidance and supporting materials

Policy guidance and supporting materials

Policy purpose: Provides guidance on medical necessity for gonioscopy and references AAO Preferred Practice Pattern guidelines and other standards of medical practice; intended as a guide to coverage decisions and not a guarantee of payment.

Providers must exercise professional judgment; state Medicaid and Medicare rules take precedence where applicable; see referenced AAO PPPs in References.

Inclusion or exclusion of codes in this clinical policy does not, by itself, guarantee that a service will be covered for a particular member. The policy references CPT code 92020 (Gonioscopy) for informational purposes only. Providers should reference current coding guidance and the member’s coverage documents when submitting claims.

Coverage determinations for gonioscopy are guided by this clinical policy but remain subject to the member’s specific benefit terms and applicable legal and regulatory requirements. This policy is a guide to medical necessity and does not constitute a contract or guarantee of payment; benefits are administered according to the coverage documents and Health Plan-level administrative policies, procedures, and applicable state or federal requirements.

This clinical policy summarizes medical necessity criteria, coding references, and supporting guidance for gonioscopy. It should be applied using professional judgment and in the context of the member’s plan documents. Providers are encouraged to verify plan-specific prior authorization and documentation requirements and to use the most current coding resources when submitting claims.

Coding Guidance and Diagnosis Codes

Referenced CPT CodesCPT

92020

Gonioscopy

ICD-10 Diagnosis Codes that Support Coverage Criteria (examples)ICD-10Covered

E08.3211	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3291	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3311	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

Applicable ICD-10 Codes (documented list)ICD-10Covered

E08.3411	Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412	... left eye
E08.3413	... bilateral
E08.3491	... without macular edema, right eye
E08.3492	... left eye
E08.3493	... bilateral
E08.3511	... proliferative diabetic retinopathy with macular edema, right eye
E08.3512	... left eye
E08.3513	... bilateral
E08.3521	... traction retinal detachment involving the macula, right eye

1–10 of 27

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Listed ICD-10 Codes — additional code groupICD-10Covered

E11.3543	Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3551	Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E11.3552	Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E11.3553	Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3591	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.37X1	Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2	... left eye
E11.37X3	... bilateral

1–10 of 22

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Comprehensive ICD-10 List (continued)ICD-10Covered

E13.3411	Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E13.3412	... left eye
E13.3413	... bilateral
E13.3491	... without macular edema, right eye
E13.3492	... left eye
E13.3493	... bilateral
E13.3511	Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E13.3512	... left eye
E13.3513	... bilateral
E13.3521	... traction retinal detachment involving the macula, right eye

1–10 of 27

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Ophthalmic and Other Supporting ICD-10 CodesICD-10Covered

H20.011	Primary iridocyclitis right eye
H20.012	Primary iridocyclitis left eye
H20.013	Primary iridocyclitis bilateral
H20.021	Recurrent acute iridocyclitis right eye
H20.022	Recurrent acute iridocyclitis left eye
H20.023	Recurrent acute iridocyclitis bilateral
H20.031	Secondary infectious iridocyclitis right eye
H20.032	Secondary infectious iridocyclitis left eye
H20.033	Secondary infectious iridocyclitis bilateral
H20.041	Secondary noninfectious iridocyclitis right eye

1–10 of 12

1/2

Additional Ophthalmic ICD-10 CodesICD-10Covered

H20.051	Hypopyon right eye
H20.052	Hypopyon left eye
H20.053	Hypopyon bilateral
H20.11	Chronic iridocyclitis right eye
H20.12	Chronic iridocyclitis left eye
H20.13	Chronic iridocyclitis bilateral
H20.21	Lens-induced iridocyclitis right eye
H20.22	Lens-induced iridocyclitis left eye
H20.23	Lens-induced iridocyclitis bilateral
H20.811	Fuchs' heterochromic cyclitis right eye

1–10 of 15

1/2

Complete Ophthalmic ICD-10 Codes (remaining list)ICD-10Covered

H21.01	Hyphema right eye
H21.02	Hyphema left eye
H21.03	Hyphema bilateral
H21.1X1	Other vascular disorders of iris and ciliary body right eye
H21.1X2	... left eye
H21.1X3	... bilateral
H21.211	Degeneration of chamber angle right eye
H21.212	... left eye
H21.213	... bilateral
H21.221	Degeneration of ciliary body right eye

1–10 of 12

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Remaining ICD-10 Codes (vascular/retinal/glaucoma/etc.)ICD-10Covered

H21.231	Degeneration of iris (pigmentary) right eye
H21.232	... left eye
H21.233	... bilateral
H21.241	Degeneration of pupillary margin right eye
H21.242	... left eye
H21.243	... bilateral
H21.251	Iridoschisis right eye
H21.252	... left eye
H21.253	... bilateral
H21.261	Iris atrophy (essential) (progressive) right eye

1–10 of 12

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Final ICD-10 Codes (trauma/contusion/penetrating wounds)ICD-10Covered

Q15.0	Congenital glaucoma
S05.11XA	Contusion of eyeball and orbital tissues, right eye, initial encounter
S05.11XD	... subsequent encounter
S05.11XS	... sequela
S05.12XA	Contusion of eyeball and orbital tissues, left eye, initial encounter
S05.12XD	... subsequent encounter
S05.12XS	... sequela
S05.51XA	Penetrating wound with foreign body of right eyeball initial encounter
S05.51XD	... subsequent encounter
S05.51XS	... sequela

1–10 of 19

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Provider Responsibilities, Documentation & Prior Auth

Prior Authorization

Prior Authorization / Coding Note

Prior authorization may be required by the health plan for gonioscopy (CPT 92020). Verify coverage and any prior authorization or precertification requirements with Ambetter Nevada prior to scheduling or claim submission.

Affected CPT code: 92020 (Gonioscopy)

Prior Authorization

Prior Authorization Requirement

This clinical policy does not specify plan-level prior authorization rules for all members. Coverage decisions and any requirement for review, prior authorization, or medical necessity determination are subject to the member’s benefit documents and Ambetter Nevada administrative policies and procedures. Consult the plan-level administrative policy or contact the health plan for definitive prior authorization requirements before providing services.

Definitions and Background Information

Gonioscopy is a diagnostic examination that uses a concave contact goniolens with oblique mirrors to visualize the iridocorneal (anterior chamber) angle. It is performed after assessment of corneal integrity (for example with fluorescein) and application of topical anesthesia, typically in a darkened room with a short, bright beam to maximize angle visualization.

Clinical indications include evaluation for angle-closure or open-angle glaucoma, assessment of peripheral anterior synechiae, angle recession after trauma, iris neovascularization (rubeosis), intraocular foreign body assessment, and lens subluxation or dislocation. When angle closure is suspected, compression (indentation) gonioscopy with a four-mirror or similar lens may be used to distinguish appositional (reversible) closure from synechial (adhesive) closure.

Corneal edema can impair visualization; topical glycerin or other measures may be used to improve the view. Procedure documentation should note corneal assessment, topical anesthesia, lens placement and removal, any irrigation performed, and a post-procedure corneal check.

Gonioscopy (definition)

DefinitionGonioscopy uses a concave contact goniolens with oblique mirrors placed against the cornea to eliminate corneal refraction and visualize the iridocorneal (anterior chamber) angle.

PurposePerformed to assess angle anatomy for angle-closure glaucoma, iris neovascularization, peripheral anterior synechiae, trauma, or other anterior chamber pathology.

Policy Summary

PayerAmbetter Nevada

PolicyGonioscopy (Clinical Policy)

Policy CodePolicy CP.VP.31

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionVerify coverage and prior authorization requirements for CPT 92020 with the plan prior to submission.

SourceLink

On This Page

Billing Rule

Coding Inclusion Disclaimer

Inclusion or exclusion of procedure codes in this clinical policy is for informational purposes only and does not guarantee coverage or reimbursement. Providers must reference current CPT manuals and the most up-to-date professional coding guidance and payer policies prior to claim submission.

Denial Risk

Denial Triggers

The source material does not list explicit denial triggers for gonioscopy; it primarily lists applicable diagnostic (ICD-10) codes and general clinical indications. Absent specific plan-level exclusions or documentation failures, standard medical necessity criteria and benefit terms govern coverage determinations.

Documentation Required

Documentation Expectations

Document the clinical indications and procedure details thoroughly: corneal integrity assessment (e.g., fluorescein results), use of topical anesthesia, lens type and placement/removal, any corneal irrigation performed, findings of the anterior chamber angle examination, and post-procedure corneal exam. While the provided text does not set explicit documentation requirements, adequate documentation supporting medical necessity and the performed service is expected for reimbursement and potential prior authorization reviews.

Note

Coverage Decisions and Administration

Providers must exercise professional judgment; this clinical policy is a guide to medical necessity and is not a guarantee of payment. Coverage and administration of benefits are subject to member benefit documents, state and federal requirements, and applicable Ambetter Nevada administrative policies. For Medicaid or Medicare members, applicable state Medicaid provisions and Medicare NCDs/LCDs take precedence where applicable.

Technique notesCorneal integrity should be checked with fluorescein and topical anesthesia applied prior to lens placement; perform in a dark room with a short bright beam to avoid pupillary constriction.

Compression (indentation) gonioscopy

DefinitionCompression (indentation) gonioscopy uses a four-mirror or similar goniolens to apply gentle pressure and determine whether apparent appositional angle closure is reversible (appositional) or permanent due to peripheral anterior synechiae (synechial).

When to useParticularly helpful when visible appositional closure is observed and the examiner needs to distinguish appositional versus synechial closure and assess extent of PAS.

Procedure settingPerform as part of gonioscopy after corneal preparation; use appropriate beam and technique to avoid inducing pupillary constriction.

ICD-10 diagnosis list (ophthalmology)

Representative ICD-10 codes (diabetic retinopathy)E11.3391, E11.3392, E11.3393, E11.3411, E11.3412 (Type 2 diabetes with nonproliferative/proliferative DR variants specifying laterality).

Hypotony / intraocular foreign body codesH44.411, H44.412, H44.413 (flat anterior chamber/hypotony); H44.601–H44.703 (retained intraocular foreign body, magnetic/nonmagnetic, laterality specified).

Glaucoma-related codesH40.813, H40.821–H40.833 (glaucoma variants including increased episcleral venous pressure, hypersecretion glaucoma, aqueous misdirection) with laterality where indicated.

AAO Preferred Practice Pattern (PPP) references

Diabetic retinopathy PPPAmerican Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Diabetic Retinopathy PPP 2019.

Retinal/ophthalmic artery occlusions PPPAmerican Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Retinal and Ophthalmic Artery Occlusions PPP 2019.

Angle-closure and open-angle glaucoma PPPsAAO Preferred Practice Pattern® Guidelines: Primary Angle-Closure Disease (2020); Primary Open-Angle Glaucoma (2020); Primary Open-Angle Glaucoma Suspect (2020).