CurrentBlue Cross Blue Shield - MassachusettsPolicy 053

Retinal Nerve Fiber Analysis (RNFA) and Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Defines medical necessity and investigational indications for RNFA/SCODI (including OCT and related imaging) for commercial and Medicare members; outlines prior authorization requirements and applicable CPT codes.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRetinal Nerve Fiber Analysis (RNFA) and Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Policy CodePolicy 053

Change TypeAnnual review (no material changes)

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient procedures; outpatient prior authorization is not required for Commercial Managed Care, PPO, and Indemnity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Medically necessary indications

3Prior auth settings described

3Primary imaging modalities

1Investigational CPT codes

Established

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.

Established add-on tests

InsufficientOcular blood flow evidence

Coverage Criteria

Medically Necessary Indications — Covered when ANY of the following indications are present:

Covered when ANY of the following indications are present:

Integration of optic nerve imaging findings with clinical examination, intraocular pressure measurements, and visual field testing is required to make diagnostic and therapeutic decisions (eg, initiation or adjustment of topical medications, monitoring intervals, or consideration of surgical intervention).

Imaging of optic nerve head and retinal nerve fiber layer — Covered when used as part of glaucoma diagnosis and management

These imaging modalities are established add-on tests used to evaluate the optic nerve and retinal nerve fiber layer and may detect structural abnormalities before functional changes are noted.

Results should be considered together with clinical examination, intraocular pressure measurements, and visual field testing to guide management decisions (monitoring, medical therapy, or surgical intervention).

Ocular blood flow measurement — Not established / insufficient evidence

Evaluation of ocular blood flow for glaucoma is considered investigational/insufficient because available studies do not demonstrate improved diagnostic accuracy or improved patient health outcomes.

Denial Risk

Investigational uses may be denied — Provider action required

Use of RNFA/SCODI (including OCT) for indications not listed (including screening) is considered investigational and may be denied. Integrate imaging results with clinical findings and document how imaging changed patient management.

Document correlation of imaging findings with clinical exam, intraocular pressure measurements, and visual field testing
Include in the medical record how imaging results affected management decisions (eg, initiation or change of medical therapy, monitoring interval changes, or decision for surgical referral)

Coding

Covered CPT Codes (when medical necessity met)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 OCT 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 requirements

Precertification/preauthorization is required when these procedures are performed in the inpatient setting. Outpatient prior authorization is not required for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity.

Inpatient: precertification/preauthorization IS REQUIRED for all products if performed inpatient.
Outpatient: prior authorization is not required for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity.

Note

Prior authorization and coding note

The policy is reviewed annually and coding clarifications have been made in prior updates; providers should refer to the current coding section for authorization and coding requirements.

Policy history shows annual reviews and coding clarifications (examples: 1/2025, 12/2016).
See coding section for current CPT designations (e.g., 92133, 92134, 92137, and investigational 0198T).

Background

Diagnosis of glaucoma requires a comprehensive ophthalmologic examination. This includes assessment of the optic nerve, formal visual field testing, and measurement of intraocular pressure (IOP). Imaging modalities such as confocal scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography (OCT) may be used as adjunctive tools, but results should be considered together with the optic nerve exam, visual fields, and IOP measurements when making diagnostic and management decisions.

Definitions of Imaging Modalities

Confocal scanning laser ophthalmoscopy — definition and examples

DefinitionImage acquisition technique that scans a laser across the retina producing high‑contrast, highly reproducible images used to estimate retinal nerve fiber layer (RNFL) thickness; does not require maximal mydriasis.

ExampleHeidelberg Retinal Tomograph is a commonly used confocal scanning laser ophthalmoscopy device.

Clinical utilityUsed to improve quality of the eye examination versus standard exam and to estimate RNFL thickness for diagnosis and monitoring of glaucoma and optic nerve disorders.

Scanning laser polarimetry — definition and example

DefinitionTechnique that uses the birefringence of the retinal nerve fiber layer to measure RNFL thickness by evaluating changes in the polarization state of reflected laser light (780‑nm diode).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRetinal Nerve Fiber Analysis (RNFA) and Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Policy CodePolicy 053

Change TypeAnnual review (no material changes)

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient procedures; outpatient prior authorization is not required for Commercial Managed Care, PPO, and Indemnity.

SourceLink

On This Page

Note

No action specified

No additional short actionable notes present.

Step Therapy

No specified step therapy

No step therapy requirements are specified for imaging; imaging results are used along with other clinical findings to guide decisions about medications, monitoring, or surgery.

Use imaging results in conjunction with other findings when making treatment decisions.

Documentation Required

Required clinical documentation

Document a comprehensive ophthalmologic examination when diagnosing glaucoma, including assessment of the optic nerve, evaluation of visual fields, and measurement of intraocular pressure (IOP).

Comprehensive exam must include optic nerve assessment, visual field evaluation, and IOP measurement.

Documentation Required

Integrate optic nerve imaging with clinical findings

Document how findings from confocal scanning laser ophthalmoscopy, scanning laser polarimetry, or optical coherence tomography are integrated with other clinical findings to support diagnostic or therapeutic decisions for glaucoma.

Indicate how imaging results were considered alongside visual fields, IOP, and clinical optic nerve exam when making management decisions.

Denial Risk

Investigational CPT code (0198T)

CPT 0198T (Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report) is considered investigational and may be denied.

0198T is listed as investigational for Commercial Managed Care, PPO, Indemnity, and Medicare products.

Denial Risk

Ocular blood flow techniques — limited evidence

Techniques to measure ocular blood flow or blood velocity have limited supporting data; the evidence is insufficient to demonstrate improved diagnostic accuracy or health outcomes, and use of these tests may not meet medical necessity.

Literature reviews have not identified studies showing these technologies improve diagnostic accuracy or patient health outcomes.
Data remain limited; evaluation of ocular blood flow is considered investigational/insufficient.

GDx is a common scanning laser polarimetry device.

Normative database & featuresGDx contains a normative database and statistical software to compare scan results with age‑matched normal subjects (same ethnic origin); modern instruments include enhanced and variable corneal compensation to account for corneal polarization.

Optical coherence tomography (OCT) — definition including spectral domain OCT and OCT angiography

DefinitionImaging modality using near‑infrared light to produce direct cross‑sectional (2‑D) measurements of the retinal nerve fiber layer, analogous in principle to B‑mode ultrasound but using light rather than sound.

VariantsIncludes spectral‑domain optical coherence tomography (SD‑OCT) developments and OCT angiography; Doppler OCT methods to assess hemodynamic parameters are also being developed.

Operational noteRequires pupil dilation and can be performed through a slit‑lamp biomicroscope with typical lenses; analysis software may include optic nerve head and macular parameter evaluation.

Laser Doppler velocimetry / Confocal scanning laser Doppler flowmetry — flow measurement techniques

Laser Doppler velocimetry — definitionTechnique that compares the frequency of reflected laser light from moving particles (eg, blood cells) with that from stationary tissue to assess flow characteristics.

Confocal scanning laser Doppler flowmetry — definitionCombines laser Doppler flowmetry with confocal scanning laser tomography; infrared laser scanning measures Doppler frequency and amplitude shifts to determine blood velocity and volume, enabling computation of total retinal blood flow and creation of retinal flow maps.

Clinical roleMethods aim to quantify retinal blood velocity and flow but are distinct from structural RNFL imaging and have limited evidence regarding impact on clinical outcomes for glaucoma.