Foresee Home AMD Monitoring — Coverage Criteria
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Policy governing coverage of the Foresee Home at‑home macular monitoring system for Medicare members when medically necessary for intermediate age-related macular degeneration (AMD). Applies to Blue Medicare plans and third-party Medicare plans administered by Blue Cross NC.
No material clinical or coverage changes in this revision.
Coverage Criteria
Indications for Coverage (Initial)
Covered when ALL of the following are met:
Foresee Home coverage criteria
- Visual acuity requirement: Best-corrected visual acuity of 20/60 or better.20/60 or better
From Indications for Coverage.
- Disease-stage requirement: Presence of intermediate dry age-related macular degeneration (intermediate AMD), defined as many medium-sized drusen or one or more large drusen.
From Indications for Coverage.
Policy Statement.
Coverage will not be approved if there is any evidence of choroidal neovascularization (CNV) on exam or a history of prior treatment with anti‑VEGF therapy.
Use of the Foresee Home system is not approved when the required coverage criteria are not all met.
Coding and Visual Acuity Requirements
Provider Actions and Prior Authorization
Prior authorization / medical necessity review required for Medicare plans
Coverage of the Foresee Home system for Medicare members is subject to prior authorization/medical necessity review and applies to Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare (HMO-POS D‑SNP), Blue Medicare Rx, and members of third‑party Medicare plans administered by Blue Cross NC. Applicable CPT‑level HCPCS codes listed in the policy are 0378T and 0379T; these codes may require medical review for medical necessity.
- Policy applies to Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare (HMO-POS D‑SNP), Blue Medicare Rx, and third‑party Medicare plans supported by Blue Cross NC.
- Applicable codes: 0378T, 0379T; inclusion does not guarantee reimbursement and may require medical review.
- The Plan may request medical records when determining medical necessity.
Submit documentation showing coverage criteria are met
Providers must submit documentation that demonstrates all coverage criteria are met when requesting approval for Foresee Home monitoring; documentation may include medical records and letters of support when requested by the Plan.
- Provide evidence that best‑corrected visual acuity is 20/60 or better and that the patient has intermediate dry AMD (many medium‑sized drusen or one or more large drusen).
- Letters of support are useful but are not sufficient alone unless they include all information needed for medical necessity determination.
Retinal specialists must document criteria for approval
Retinal specialists seeking program approval should provide documentation demonstrating the patient meets the policy's coverage criteria; the Plan may request medical records and letters of support during medical necessity review.
- Document best‑corrected visual acuity and clinical findings consistent with intermediate dry AMD.
- Be prepared to supply full medical records if requested by the Plan.
Denial risk: missing criteria, CNV, or prior anti‑VEGF therapy
Coverage will be denied if the required coverage criteria are not all met, or if there is any evidence of choroidal neovascularization (CNV) on exam or prior treatment with anti‑VEGF therapy.
- Denial occurs when any single required criterion is missing.
- Prior anti‑VEGF treatment or any exam evidence of CNV excludes coverage.
Background
Age‑related macular degeneration (AMD) is a progressive retinal disease that can lead to central vision loss; clinical distinctions between dry (non‑neovascular) and wet (neovascular) AMD are critical for coverage considerations because the presence of neovascularization changes both prognosis and treatment. The Foresee Home system is intended for monitoring patients with intermediate dry AMD to detect early progression; however, coverage is explicitly excluded when there is any evidence of choroidal neovascularization or prior anti‑VEGF therapy, since those findings indicate neovascular (wet) disease and require different management.
Definitions
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