CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Posterior Segment

Policy governing the medical necessity and coding for posterior segment scanning computerized ophthalmic diagnostic imaging (e.g., OCT) for Medicare Advantage and commercial members; affects providers performing and billing posterior segment SCODI in the applicable plan population.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Posterior Segment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateMar 6, 2026

Key ActionVerify member-specific benefits and prior authorization requirements before billing; file CPT codes 92133, 92134, or 92137 with an applicable ICD-10 diagnosis code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes listed as medically necessary

posterior segmentAnatomic region covered

Medicare Adv & CommercialPlan types specified

CMS LCD/LCAExternal coverage references

Coverage Criteria

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Medically Necessary Indications

Covered when ANY of the following clinically indicated reasons are present:

Indications: 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 nerve fiber layer changes; diagnose early glaucoma and monitor glaucoma treatment; differentiate causes of other optic nerve disorders when a diagnosis is in doubt; 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; differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields; detect further loss of optic nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss; follow glaucoma suspects; monitor for chloroquine or hydroxychloroquine retinal toxicity during long-term therapy; evaluate macular abnormalities, retinal thickening/edema, and vitreo-retinal relationships to guide treatment and surgical planning.

Aggregated from policy indications.

Coverage determinations for SCODI services are governed by the member's specific plan documents. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a particular diagnostic test is covered under that contract, as benefits may vary between groups and plans.

Under the Medical Criteria section the policy states Not applicable. There are no explicit items listed in this document as "not medically necessary."

Coding

Covered CPT CodesCPTCovered

92133	Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
92134	Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), 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

Provider Actions & Billing Requirements

Billing Rule

Coverage & Billing Verification

Benefits may vary between groups/contracts. Verify member-specific coverage by checking the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before providing or billing for diagnostic testing.

Coverage depends on group/contract benefits; verify Evidence of Coverage or Subscriber Agreement prior to service.
CPT codes 92133, 92134, and 92137 must be filed with the appropriate ICD-10 diagnosis code(s) as specified in the policy attachment.
Follow correct coding guidelines when billing for global services or when filing professional (26) and technical (TC) components.

Prior Authorization

Prior authorization is not applicable under this policy; however, always verify member-specific contract requirements as some groups or plans may have different administrative requirements.

Documentation Required

Coding Requirements

File CPT 92133, 92134, and 92137 only when accompanied by an appropriate ICD-10 diagnosis code from the policy's ICD-10 lists. Ensure CPT/ICD-10 pairings match the code-specific diagnosis lists and include the correct component modifiers when applicable.

CPT 92133 — include applicable ICD-10 diagnosis code from the 92133 list.
CPT 92134 — include applicable ICD-10 diagnosis code from the 92134 list.
CPT 92137 — include applicable ICD-10 diagnosis code from the 92137 list.
Include modifier 26 or TC when billing professional or technical components separately, per coding guidance.

Background

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), for example optical coherence tomography (OCT), is a non‑invasive, non‑contact imaging technique that produces high‑resolution cross‑sectional tomographic images of the eye. Posterior segment SCODI provides detailed visualization of the retina, choroid, optic nerve, and vitreoretinal relationships to aid in diagnosis and management of posterior ocular disease, including earlier detection of optic nerve and retinal nerve fiber layer changes, assessment of macular pathology, guidance for surgical planning, and monitoring of glaucoma and retinal conditions.

Definitions

Posterior segment SCODI — definition

DefinitionHigh-resolution tomographic imaging of retinal, choroidal, optic nerve and vitreoretinal relationships used for diagnosis and management of posterior ocular disease.

PurposeEnables earlier detection of optic nerve and retinal nerve fiber layer pathologic changes prior to visual field loss, allowing earlier intervention for glaucoma and glaucoma suspects.

Anatomic scopePosterior segment structures including retina, choroid, optic nerve, retinal nerve fiber layer, macula, and vitreo-retinal/vitreopapillary relationships.

Clinical usesAssessment of retinal/choroidal layers and macular thickness, detection of retinal edema, discrimination among glaucoma presentations, and surgical planning based on vitreo-retinal relationships.

Technique characteristicsNon-invasive, non-contact imaging producing high-resolution, cross-sectional tomographic images of ocular structures.