Arizona Complete Health Fluorescein Angiography Coverage

Coverage Criteria for Fluorescein Angiography

Medically Necessary Indications

Covered when ANY of the following indications are present (initial evaluation or symptomatic presentation) OR when specified follow-up timing criteria for disease monitoring are met:

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

See enumerated subitems in policy

Symptomatic evaluation: Evaluation of a patient presenting with sudden vision loss (especially central), blurred vision, distortion, or other symptoms suggesting subretinal neovascularization with abnormal fundus/retina findings on ophthalmoscopy.

Diabetic retinopathy monitoring and post-treatment follow-up: Evaluation of patients with nonproliferative (background) or proliferative diabetic retinopathy without macular edema. Frequency determined by disease progression and treatment performed. For treated eyes, fluorescein angiography may be performed at 6 weeks post-treatment and as often as every 8–12 weeks to assist in management.

Background retinopathy: intraretinal microaneurysms, hemorrhages and hard exudates; Proliferative retinopathy: neovascularization arising from the disc or retinal vessels.

Follow-up timing for select retinal diseases: Age-related macular degeneration (nonexudative): every 6–12 months. Exudative AMD: 1–2 weeks, 1 month, 6 weeks post photocoagulation, then every 6–12 months per policy schedule.

Specific timing items appear under policy subitems

Other covered conditions: Evaluation of chorioretinitis, chorioretinal scars/choroidal degeneration, dystrophies, hemorrhage and rupture or detachment; macular disorders including macular edema and cystoid macular edema; central and branch retinal vein occlusion; tumors of the choroid and retina; retinal arterial disease; ocular tumors; visual loss related to systemic disease; and optic disc disease.

Diagnosis codes supporting coverage

Covered when a listed ICD-10-CM diagnosis code is present to support the covered ocular condition

Diagnosis present: Presence of any listed ICD-10-CM diagnosis code from the sections of this policy supports coverage for fluorescein angiography.

Codes are listed by disease group and laterality (diabetic retinopathy, other specified diabetes, inflammatory and other retinal/choroidal disorders, etc.); no additional clinical logic is specified in this section

No explicit exclusions are listed in this portion of the clinical policy.

No explicit exclusions are stated in the diagnosis code listings; this section only enumerates ICD-10-CM codes that support coverage for fluorescein angiography.

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence. For Medicare members, applicable Medicare NCDs, LCDs, and Medicare Coverage Articles should be reviewed and take precedence where relevant.

No explicit 'Not Medically Necessary' conditions are specified in this segment of the policy.

No explicit 'not medically necessary' statements appear in the diagnosis code sections; the document portion lists codes that support coverage rather than describing noncoverage scenarios.

Coding — Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

92235

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

ICD-10 Codes Supporting Coverage (sample; full list continues in document)ICD-10

A18.53	Tuberculous chorioretinitis
B20	Human immunodeficiency virus [HIV] disease
B39.4	Histoplasmosis capsulati unspecified
B39.5	Histoplasmosis duboisii
B39.9	Histoplasmosis, unspecified
B58.01	Toxoplasma chorioretinitis
C69.21	Malignant neoplasm of right retina
C69.22	Malignant neoplasm of left retina
C69.31	Malignant neoplasm of right choroid
C69.32	Malignant neoplasm of left choroid

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ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered

E10.3313	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3391	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E10.3392	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3411	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E10.3412	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3491	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E10.3492	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

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ICD-10 Codes that Support Coverage CriteriaICD-10Covered

H35.23	Other non-diabetic proliferative retinopathy, bilateral
H35.3111	Nonexudative age-related macular degeneration, right eye, early dry stage
H35.3112	Nonexudative age-related macular degeneration, right eye, intermediate dry stage
H35.3113	Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement
H35.3114	Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement
H35.3121	Nonexudative age-related macular degeneration, left eye, early dry stage
H35.3122	Nonexudative age-related macular degeneration, left eye, intermediate dry stage
H35.3123	Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement
H35.3124	Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement
H35.3131	Nonexudative age-related macular degeneration, bilateral, early dry stage

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Coding summary (metadata)

Coding metadataReferenced CPT code in policy: 92235 — Fluorescein angiography (includes multi-frame imaging) with interpretation and report

ICD-10 code groups referencedMultiple ICD-10-CM diagnosis blocks (E10–E13 series for diabetic retinopathy/mac edema are listed in detail)

Policy number / statusPolicy CP.VP.28 — stance: covered with criteria

Provider Actions, Documentation, and Prior Authorization

Billing Rule

Coding and CPT inclusion disclaimer

CPT 92235 (Fluorescein angiography with interpretation and report) is the referenced procedure code for this clinical policy. Inclusion or exclusion of any codes does not guarantee coverage; providers should reference the most current CPT coding guidance and payer billing rules prior to claim submission.

Affected CPT: 92235 — Fluorescein angiography (includes multi-frame imaging) with interpretation and report

Documentation Required

Diagnosis codes (supporting coverage)

The policy lists ICD-10-CM diagnosis codes that support medical necessity for fluorescein angiography. Use an appropriate, specific diagnosis code that reflects the patient’s retinal condition when requesting authorization or submitting claims.

Background

Fluorescein angiography is a diagnostic imaging technique that uses intravenous sodium fluorescein and blue light photography to evaluate retinal and choroidal circulation. It is used to detect leaking capillaries, neovascularization, microaneurysms, and retinal pigment epithelium defects, and provides a permanent photographic or electronic record essential for diagnosis and treatment planning. Baseline color and red‑free (black‑and‑white) images are taken prior to injection, and the procedure is reported using CPT code 92235.

Definitions and Key Terms

Fluorescein angiography

DefinitionFluorescein angiography: technique examining retinal and choroidal circulation by intravenous sodium fluorescein injection and photographing fluorescence after blue light excitation (~490 nm).

PurposeDetects leaking capillaries, neovascularization, microaneurysms, and defects of the retinal pigment epithelium to guide diagnosis and treatment planning (including laser therapy).

RecordA permanent photographic or electronic record of the study is always made.

Red-free (black-and-white) imaging

DefinitionRed-free (black-and-white) imaging: black-and-white images filtered red-free (green filter) taken prior to fluorescein injection to increase contrast of fundus structures.

Technique note