CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionPrior authorization review is not required for SCODI/OCT posterior segment imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

1Primary CPT code listed

7Listed clinical indications

Coverage Summary

Defines coverage and medical necessity for posterior segment scanning computerized ophthalmic diagnostic imaging (SCODI)/OCT for Medicare Advantage and commercial products, including indications, coding, and prior authorization information. SCODI/OCT is a non-invasive, non-contact imaging technique that produces high-resolution, cross-sectional tomographic images of ocular structures for evaluation of anterior and posterior segment disease. Coverage stance: covered_with_criteria. Effective date: 2022-01-01.

Policy metadata

PayerBlue Cross Blue Shield - Rhode Island

Policy titleScanning Computerized Ophthalmic Diagnostic Imaging

Policy numberN/A

Effective date2022-01-01

StatusCURRENT

Primary CPT code listed92133

Listed clinical indicationsDiagnose/manage retinal and neuro-ophthalmic diseases; Differentiate nerve disorder causes; Diagnose/monitor early glaucoma; Use when visual field testing insufficient/unreliable; Differentiate optic nerve vs visual field discrepancy; Detect further nerve/RNFL loss with advanced damage; Follow glaucoma suspects

Medical-Necessity Criteria

Medically Necessary Indications for Posterior Segment OCT/SCODI

Posterior Segment OCT/SCODI is considered reasonable and necessary for diagnosis and management when any of the following clinical conditions are present:

Medically Necessary Indications

Indication 1: Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases involving changes in the optic nerve, subretinal and intraretinal changes, vitreoretinal relationships, and changes in the nerve fiber layer
Indication 2: Differentiate causes of other nerve disorders when a diagnosis is in doubt
Indication 3: Diagnose early glaucoma and monitor glaucoma treatment
Indication 4: Diagnose and manage the patient's condition when visual field results are insufficient or when reliable visual field testing cannot be performed due to visual, physical, mental, or age constraints
Indication 5: Differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields
Indication 6: Detect further loss of nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss
Indication 7: Follow glaucoma suspects

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title": "Medically Necessary Indications for Posterior Segment OCT/SCODI"

Provider Actions

Prior Authorization

Prior authorization not required

Prior authorization review is not required for SCODI/OCT posterior segment imaging.

Documentation Required

Clinical indication documentation required

When billing, document one of the medically necessary indications (e.g., glaucoma diagnosis/monitoring, retinal/neuro-ophthalmic disease, insufficient/unreliable visual field testing, discrepancy between nerve appearance and visual fields, follow glaucoma suspects) to support medical necessity.

92133

Billing Rule

Component billing guidance

Follow correct coding guidelines regarding filing for the global service or professional/technical component when reporting CPT 92133.

92133

Background & Definitions

SCODI/OCT is a non-invasive, non-contact imaging technique that produces high-resolution cross-sectional tomographic images of ocular structures and is used for evaluation of anterior and posterior segment disease. For the posterior segment, SCODI enables earlier detection of nerve and retinal nerve fiber layer pathologic changes before visual field loss, allowing therapy to be initiated before irreversible vision loss. It discriminates among patients with normal or elevated intraocular pressure with or without glaucoma, permits high-resolution assessment of retinal edema and macular thickness, and displays vitreo-retinal and vitreo-papillary relationships to assist in surgical planning and assessment. The CPT code 92133 is the listed code for posterior segment SCODI with interpretation and report.

SCODI: Scanning Computerized Ophthalmic Diagnostic Imaging; non-invasive tomographic imaging of ocular structures.

Type	Name (and Number)
LCD	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34380)
NCD	Local Coverage Article: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) Billing Coding (A56537)

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionPrior authorization review is not required for SCODI/OCT posterior segment imaging.

SourceLink

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Medical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Definitions

Medicare Determinations

Revision History