CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) / Posterior Segment OCT

Policy governs coverage and medical necessity of posterior segment scanning computerized ophthalmic diagnostic imaging (SCODI)/OCT for evaluation and management of retinal and neuro-ophthalmic diseases for BCBSRI members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) / Posterior Segment OCT

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionPrior authorization is not required for SCODI/OCT services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92133Primary CPT code listed as medically necessary

Not requiredPrior authorization requirement

12/30/2021Last policy update

01/01/2022Effective date

Coverage Criteria for Posterior Segment SCODI / OCT

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Covered indications for posterior segment SCODI/OCT

Posterior segment OCT/SCODI is considered reasonable and necessary for the following diagnostic and management indications:

Indications list: Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases involving changes in the optic nerve, subretinal and intraretinal changes, vitreo-retinal relationships, and changes in the nerve fiber layer.

Each bulleted indication listed in the policy is a covered reason for posterior segment OCT/SCODI.

Indications list: Differentiate causes of other nerve disorders when a diagnosis is in doubt.

Indications list: Diagnose early glaucoma and monitor glaucoma treatment.

Indications list: Evaluate and manage the patient when visual field results are insufficient or when reliable visual field testing cannot be performed due to visual, physical, mental, or age constraints.

Indications list: Differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields.

Indications list: Detect further loss of nerve or retinal nerve fiber layer in the presence of advanced optic nerve damage and advanced visual field loss.

Indications list: Follow glaucoma suspects.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization review is not required for scanning computerized ophthalmic diagnostic imaging (SCODI) / OCT services.

Note

Benefit / Coverage Variability

Benefits and coverage may vary by contract. Providers should refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable diagnostic testing and coverage determinations.

Documentation Required

Coding / Claims Documentation

For Medicare Advantage Plans and Commercial Products, use CPT 92133 for scanning computerized ophthalmic diagnostic imaging of the posterior segment with interpretation and report (optic nerve). Follow correct coding guidelines regarding billing the global service or the professional and technical components as applicable.

CPT 92133 — SCODI posterior segment; with interpretation and report; unilateral or bilateral; optic nerve
Bill global service or separate professional (26) and technical (TC) components per coding guidelines

Documentation Required

Member Notification for Non‑Covered Services

For information on member-specific benefits and eligibility, contact the provider call center. If a service is determined to be not covered, providers may not bill the member unless the member has been informed and has provided written agreement in advance to accept financial responsibility. Refer to your participation agreement(s) for applicable provisions.

Verify member coverage prior to providing services
Obtain written agreement before billing a member for non-covered services

Background

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), also described as posterior segment optical coherence tomography (OCT), is a non-invasive, non-contact imaging technique that produces high-resolution, cross-sectional tomographic images of the ocular posterior segment. It is used to evaluate retinal and optic nerve structure, detect early glaucomatous change and retinal pathology, assess macular thickness and retinal edema, and visualize vitreoretinal relationships to aid diagnostic and surgical decision-making.

Definitions

SCODI — definition of Scanning Computerized Ophthalmic Diagnostic Imaging

TermScanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

DefinitionA non-invasive, non-contact imaging technique that produces high-resolution, cross-sectional tomographic images of ocular structures.

Primary useEvaluation of anterior segment and posterior segment ocular disease.

Image characteristicsHigh-resolution, cross-sectional tomographic images suitable for detecting retinal and optic nerve pathology.

Clinical valueEnables assessment of macular thickness, retinal nerve fiber layer and vitreo-retinal relationships for diagnosis, monitoring, and surgical planning.