CurrentBlue Cross Blue Shield - MassachusettsPolicy 053

Retinal Nerve Fiber Analysis (RNFA), Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), Posterior Segment Optical Coherence Tomography, and Ocular Blood Flow Measurement

This policy governs coverage and prior authorization for retinal nerve fiber analysis (RNFA)/scanning computerized ophthalmic diagnostic imaging (SCODI), posterior segment OCT, and techniques to measure ocular blood flow for Blue Cross Blue Shield Massachusetts members. It affects providers performing and billing for these diagnostic ophthalmic imaging and ocular blood flow procedures.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRetinal Nerve Fiber Analysis, SCODI, Posterior Segment OCT, and Ocular Blood Flow Measurement

Policy CodePolicy 053

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient procedures and document a comprehensive ophthalmologic exam when submitting imaging for coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7medically necessary indications

0198Tinvestigational CPT

Prior authPA required inpatient

establishedoptic nerve/RNFL imaging

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

insufficientocular blood flow

ongoingpolicy reviews

Coverage Criteria

Medically Necessary Indications for RNFA/SCODI/OCT

RNFA/SCODI/posterior segment OCT may be medically necessary when ALL of the following clinical situations are met:

Medically necessary indications: To diagnose early glaucoma and monitor glaucoma treatment; to diagnose and manage the patient's condition when visual field results are insufficient or reliable visual field testing cannot be performed due to visual, physical, mental, or age constraints; to differentiate causes of other optic nerve disorders when a diagnosis is in doubt; to differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields; to diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases involving changes in the optic nerve, subretinal/intraretinal layers, vitreo-retinal relationships, and nerve fiber layer; to detect further loss of optic nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss; to follow glaucoma suspects.

Seven distinct indications listed in policy text.

Investigational / Not Covered Uses

The following are considered investigational and therefore not covered:

Investigational procedures: Retinal nerve fiber analysis/SCODI (including OCT) for conditions not listed above (including screening) is investigational; measurement of ocular blood flow, pulsatile ocular blood flow, or blood flow velocity in the diagnosis and follow-up of individuals with glaucoma is investigational.

CPT 0198T is listed as investigational for Commercial Members.

Optic nerve and RNFL imaging

Covered when used as add-on tests in the evaluation and management of glaucoma or suspected glaucoma:

Imaging for glaucoma: Confocal scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography of the optic nerve and retinal nerve fiber layer are established add-on tests that may be used to diagnose and manage patients with glaucoma and suspected glaucoma; results should be considered along with other clinical findings (eg, visual fields, intraocular pressure, clinical optic nerve assessment) to guide treatment decisions.

Evidence sufficient to determine improvement in net health outcome; imaging results are used with other findings to guide medication, monitoring, or surgery.

Ocular blood flow techniques

Not established — insufficient evidence to support routine clinical use:

Ocular blood flow measurement: Techniques to measure ocular blood flow or ocular blood velocity (eg, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, laser speckle flowgraphy, Doppler ultrasonography, and related measures) have limited data; literature reviews have not identified studies showing these methods improve diagnostic accuracy or health outcomes in patients with glaucoma.

Measurement of ocular blood flow (including CPT 0198T) is considered investigational and may be denied due to insufficient evidence.

Retinal nerve fiber analysis (RNFA)/scanning computerized ophthalmic diagnostic imaging (SCODI), including posterior segment optical coherence tomography (OCT), when performed for conditions that are not specifically listed as medically necessary in this policy (for example, routine screening or other unlisted indications), is considered investigational and therefore not covered. The policy explicitly states that RNFA/SCODI/OCT for conditions not listed above (including, but not limited to, screening) is investigational.

Techniques intended to measure ocular blood flow or ocular blood velocity (for example, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, laser speckle flowgraphy, Doppler ultrasonography, and related correlations with OCT angiography) currently have limited data and literature reviews have not identified studies demonstrating that these techniques improve diagnostic accuracy or health outcomes. Consequently, such ocular blood flow measurement techniques lack sufficient evidence to be considered established diagnostic tools for altering glaucoma management.

Measurement of ocular blood flow methods — including the specific CPT code 0198T (measurement of ocular blood flow by repetitive intraocular pressure sampling) — for the purposes of diagnosing or following individuals with glaucoma is considered investigational and not medically necessary for Commercial members. The policy notes that available data are limited and do not demonstrate improved net health outcomes for glaucoma diagnosis or follow-up when ocular blood flow measurement is used.

Using evaluation of ocular blood flow to guide glaucoma management is considered investigational/insufficient because the literature has not shown that these measurements improve diagnostic accuracy or clinical outcomes. Although some studies suggest these parameters may help explain variability in visual field changes among patients, the evidence is currently inadequate to support changing treatment decisions based on ocular blood flow measurements.

Coding

Covered CPT Codes (subject to medical necessity)CPTCovered

92133	Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment; with interpretation and report; unilateral or bilateral; optic nerve.
92134	Scanning computerized ophthalmic diagnostic imaging, posterior segment; with interpretation and report; unilateral or bilateral; retina.
92137	Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report; unilateral or bilateral; retina, including QCT angiography.

Investigational CPT CodeCPTNot Covered

0198T

Measurement of ocular blood flow by repetitive intraocular pressure sampling; with interpretation and report.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required for Inpatient Procedures

For services described in this policy, precertification/preauthorization IS REQUIRED for products if the procedure is performed inpatient.

Applies to all products covered by this policy when the procedure is performed in an inpatient setting.

Prior Authorization

Outpatient Prior Authorization Varies by Product

Outpatient prior authorization requirements vary by product. For Commercial Managed Care (HMO and POS) outpatient services, prior authorization is not required. For Commercial PPO and Indemnity outpatient services, prior authorization requirements may apply — check product-specific guidance and the member's contract benefits.

Providers must verify prior authorization requirements by product and by site of service before scheduling outpatient procedures.

Definitions and Test Descriptions

Confocal Scanning Laser Ophthalmoscopy — definition / key facts

TermConfocal Scanning Laser Ophthalmoscopy

DefinitionAn image acquisition technique that scans a laser across the retina with a detector system to produce high-contrast, highly reproducible images used to estimate retinal nerve fiber layer thickness; does not require maximal mydriasis (eg, Heidelberg Retinal Tomograph).

Clinical noteIntended to improve quality of examination compared with standard ophthalmologic exam and to provide reproducible RNFL estimates.

Scanning Laser Polarimetry — definition / key facts

TermScanning Laser Polarimetry

DefinitionTechnique that measures changes in the polarization state of a laser beam (eg, 780-nm diode) after passing through the birefringent retinal nerve fiber layer to directly assess RNFL thickness; devices (eg, GDx) include normative databases and can be performed without pupil dilation.

Background

A comprehensive ophthalmologic examination is required to diagnose glaucoma; no single test is adequate. The exam should include assessment of the optic nerve, measurement of intraocular pressure, and visual field testing. Imaging tests such as confocal scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography are considered supportive add-on tests and their results should be interpreted in the context of the comprehensive clinical examination rather than as standalone diagnostic proof.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRetinal Nerve Fiber Analysis, SCODI, Posterior Segment OCT, and Ocular Blood Flow Measurement

Policy CodePolicy 053

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient procedures and document a comprehensive ophthalmologic exam when submitting imaging for coverage.

SourceLink

On This Page

Billing Rule

Code Inclusion/Exclusion Is Not Coverage

Inclusion or exclusion of a code in this policy does not, by itself, constitute or imply that the service described by the code is a covered benefit or that the member is eligible for coverage or reimbursement. Medical necessity criteria must be met and the member's contract benefits in effect at the time of service determine coverage.

Providers should report all services using current industry-standard CPT/HCPCS/ICD diagnosis codes and appropriate modifiers.
The codes listed in this policy are for informational purposes and are not an all-inclusive list.

Documentation Required

Imaging Documentation Required to Support Medical Necessity

A comprehensive ophthalmologic examination is required for diagnosis and management of glaucoma and must include assessment of the optic nerve, evaluation of visual fields, and measurement of intraocular pressure. Imaging studies such as confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) may be used as adjunctive tools. Documentation submitted with imaging requests must support clinical use in the member's management plan (e.g., baseline/serial imaging for monitoring progression, specific findings on exam or visual fields that justify the test).

Document the comprehensive ophthalmologic exam findings (optic nerve appearance, visual field results, IOP measurements) when requesting CSLO, SLP, or OCT.
Indicate how imaging results will affect management (monitoring interval, medication change, surgical consideration).

Step Therapy

No step therapy requirements are specified in this policy for imaging or ocular blood flow testing. If applicable, product-specific medical management programs (including any step therapy) must be followed and verified prior to service.

Verify whether the member's benefit plan imposes any step-therapy or prior conservative management requirements for related treatments (e.g., medication trials to lower IOP) that could affect coverage decisions.

Denial Risk

Ocular Blood Flow Techniques — Limited Evidence

Techniques to evaluate ocular blood flow (including pulsatile ocular blood flow and other blood flow velocity measures) are considered experimental/investigational due to limited evidence that they improve diagnostic accuracy or patient health outcomes. Requests for ocular blood flow testing may be denied when documentation does not demonstrate that results will meaningfully change management or improve outcomes.

Literature reviews have not identified sufficient evidence that ocular blood flow measurements improve net health outcomes.
When requesting coverage, provide clinical rationale showing how results will alter treatment decisions or improve outcomes; absent that, testing is likely to be considered investigational.

Clinical noteCurrent instruments include enhanced and variable corneal compensation to account for corneal polarization; evaluation can be completed in about 10 minutes.

Optical Coherence Tomography (OCT) — definition / key facts

TermOptical Coherence Tomography (OCT)

DefinitionNear-infrared light–based imaging that provides direct cross-sectional measurement of the retinal nerve fiber layer (similar principles to B-mode ultrasound); requires pupil dilation and includes spectral-domain OCT and angiography/Doppler OCT variants.

Clinical noteAnalysis software developments include optic nerve and macular parameters as well as hemodynamic measures with Doppler OCT and OCT angiography.

Pulsatile Ocular Blood Flow — definition / key facts

TermPulsatile Ocular Blood Flow

DefinitionThe pulsatile variation in intraocular pressure from cardiac systole due to blood flow into the eye; detectable by continuous IOP monitoring and convertible to a volume measurement using the relation between ocular pressure and ocular volume.

Clinical notePulsatile blood flow primarily reflects choroidal vessel flow, which is relevant because the optic nerve receives substantial choroidal circulation.

Laser Doppler Velocimetry — definition / key facts

TermLaser Doppler Velocimetry

DefinitionA technique that compares the frequency of laser light reflected from moving particles with that from stationary tissue to assess blood flow dynamics.

Clinical noteUsed as one method to evaluate ocular blood velocity; part of several investigational ocular blood flow techniques.

Confocal scanning laser Doppler flowmetry — definition / key facts

TermConfocal scanning laser Doppler flowmetry

DefinitionCombines laser Doppler flowmetry with confocal scanning laser tomography: infrared laser light scans the retina and Doppler shift frequency/amplitude from reflected light are used to determine blood velocity and volume and to map retinal blood flow.

Clinical noteComputes total blood flow and creates a physical map of retinal flow values; considered among techniques with limited evidence for clinical management of glaucoma.