Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — posterior segment (OCT)
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Policy governing coverage and coding for posterior segment scanning computerized ophthalmic diagnostic imaging (SCODI/OCT) for Medicare Advantage and commercial products; intended for providers ordering or billing posterior-segment OCT imaging.
No material clinical or coverage changes in this revision.
Coverage Criteria — Posterior Segment SCODI (OCT)
Medically Necessary Indications
Posterior segment OCT is considered reasonable and necessary for the following clinical indications:
Coverage for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI/OCT) is governed by the member's specific benefit plan. Benefits may vary between groups/contracts; providers must refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether diagnostic testing is covered for a particular member.
Medical Criteria: Not applicable. This policy document does not list any explicit services or indications designated as not medically necessary within the text of the policy.
Coding — CPT and Diagnosis Codes
Provider Actions and Billing Requirements
Prior authorization not applicable
Prior authorization is not required for the services covered by this policy.
No specified provider action
No additional provider action summary was provided in the policy source or brief; there is no step-therapy or other required sequence of services specified.
File CPT with corresponding ICD-10 diagnosis from attachment
When billing CPT codes 92133, 92134, or 92137, submit the claim with one of the ICD-10 diagnosis codes listed in the ICD-10 attachment for the applicable CPT code and follow correct coding guidelines for global versus professional/technical components.
Confirm member-specific benefits to avoid denial
Verify member benefits before ordering or billing posterior segment OCT because benefits may vary by group/contract and lack of coverage in the member’s benefit booklet, Evidence of Coverage, or Subscriber Agreement may result in denial or non-coverage.
- Confirm applicable diagnostic testing coverage in the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement
Background — SCODI / OCT Overview
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), commonly referred to as optical coherence tomography (OCT), is a non‑invasive, non‑contact imaging technique that produces high‑resolution cross‑sectional images of ocular structures. Posterior segment OCT images the retina, optic nerve head, retinal nerve fiber layer and choroid, enabling earlier detection of optic nerve and retinal nerve fiber layer changes prior to measurable visual field loss and assisting in the diagnosis and management of retinal, choroidal and neuro‑ophthalmic diseases.
Posterior segment SCODI/OCT is used to assess macular thickness and architecture, evaluate vitreoretinal interfaces, differentiate optic nerve disorders when the diagnosis is in doubt, monitor glaucoma and glaucoma suspects, follow progression in advanced optic nerve or visual field damage, and aid monitoring for drug‑related retinopathy such as long‑term chloroquine (CQ) or hydroxychloroquine (HCQ) toxicity.
Definitions and Monitoring Indications
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