CurrentCapital BluecrossPolicy MP 2.056

Ophthalmologic techniques that evaluate the posterior eye segment

Defines medical necessity and investigational indications for techniques that evaluate the optic nerve, retinal nerve fiber layer (RNFL), and ocular blood flow (e.g., CSLO, SLP, OCT, blood flow measures) for diagnosis and management of glaucoma and other optic nerve disorders.

Policy Summary

PayerCapital Bluecross

PolicyOphthalmologic techniques that evaluate the posterior eye segment

Policy CodePolicy MP 2.056

Change TypeNo material clinical or coverage changes in this revision

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionDocument comprehensive ophthalmologic exam findings (optic nerve assessment, visual fields, IOP) and the clinical indication to support medical necessity for RNFL analysis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ListedCovered indications

ListedInvestigational uses

MP 2.056Policy

2/1/2026Effective

Insufficient for ocular blood flow

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PartialDocument portion

Coverage Criteria

Medically necessary indications for RNFL/optic nerve analysis

Covered when ALL of the following are met for RNFL/optic nerve analysis using CSLO, SLP, or OCT:

Covered indications: Patient has one of: glaucoma or glaucoma suspect; multiple sclerosis; increased intracranial pressure; optic neuritis; or other optic nerve disorders.

Analysis using CSLO, SLP, or OCT for these indications is considered medically necessary.

Investigational indications

Not covered / investigational:

Investigational uses: RNFL analysis for all other indications not listed as medically necessary; patient-initiated home optical coherence tomography (OCT) devices for any indication; measurement of ocular blood flow, pulsatile ocular blood flow, or blood flow velocity for any indication.

Document states insufficient evidence to support a general conclusion concerning health outcomes or benefits for these uses.

Optic nerve / RNFL imaging — Coverage stance and evidence summary

Coverage stance and evidence summary

Optic nerve and RNFL imaging for glaucoma: Confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) can be used to evaluate the optic nerve and retinal nerve fiber layer in patients with glaucoma and suspected glaucoma; literature and specialty society guidance describe these as established add-on tests used to diagnose and manage glaucoma, and the evidence is sufficient to determine a meaningful improvement in net health outcome.

These imaging modalities are considered clinically useful when interpreted with other examination findings to guide glaucoma management.

Ocular blood flow evaluation — Coverage stance

Ocular blood flow / velocity measurement

Ocular blood flow techniques: Techniques to measure ocular blood flow or blood velocity (for example: laser speckle flowgraphy, color Doppler imaging, Doppler Fourier domain OCT, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, and retinal functional imaging) have limited data; association studies exist but there is insufficient evidence these technologies improve diagnostic accuracy or health outcomes in glaucoma management.

Use of ocular blood flow or blood velocity measurements is considered investigational due to insufficient evidence of benefit.

Investigational / Not Covered Diagnoses

Listed ICD-10-CM diagnoses are described as investigational and therefore not covered in this document segment.

Investigational ICD-10-CM diagnoses: Multiple specific H40.xx ICD-10-CM diagnosis codes (see listed codes in source chunks) are designated investigational and are not covered for the posterior segment evaluation techniques described in this policy segment.

Partial list provided in this document segment; refer to the full policy for the complete list of investigational diagnosis codes.

The policy designates the use of patient-initiated home optical coherence tomography (home OCT) devices and techniques to measure ocular blood flow (including pulsatile ocular blood flow and blood flow velocity measures) as investigational for all indications. The source states there is insufficient evidence to conclude these approaches improve health outcomes and therefore they are not covered under this segment of the policy.

The following procedure codes are listed as investigational and therefore not covered in this policy segment: 0198T, 0604T, 0605T, and 0606T.

A series of ICD-10-CM H40.xx diagnosis codes are explicitly identified in the document as investigational and therefore not covered. The policy maps multiple specific H40.* codes (see the investigational diagnosis listings in the source) to this not-covered designation.

Policy history and administrative notes are recorded in this segment, documenting code additions and removals and prior consensus reviews. These history entries do not introduce additional explicit exclusions beyond those stated elsewhere in the policy excerpts shown.

Analysis of the optic nerve (retinal nerve fiber layer) using CSLO, SLP, or OCT is considered investigational (not medically necessary) when performed for indications other than the listed covered conditions (glaucoma or glaucoma suspects, multiple sclerosis, increased intracranial pressure, optic neuritis, or other optic nerve disorders).

The policy concludes that use of techniques to assess ocular blood flow (including pulsatile ocular blood flow and blood flow velocity measures) currently lacks sufficient data showing improved diagnostic accuracy or better health outcomes. Association studies exist, but the evidence is insufficient to determine effects on health outcomes, and these measurements are therefore considered investigational.

Designated ICD-10-CM codes within the H40 series shown in this document extract are identified as investigational and therefore not covered. The source lists multiple specific H40.* codes mapped to the investigational/not-covered category.

The chunks in this portion of the document include policy history and administrative updates but do not contain standalone statements labeled explicitly as 'not medically necessary' beyond the investigational determinations provided elsewhere in the policy excerpts.

Coding

Provider Actions and Billing Guidance

Prior Authorization

Product-specific prior authorization

This policy applies only to certain Capital Blue Cross products and program variations. Some product lines may have different prior authorization or medical policy requirements. Providers should verify product-specific prior authorization and coverage rules before ordering services (for example, FEP PPO follows the FEP Medical Policy Manual: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies).

Check member benefit terms and product-specific manuals for prior authorization requirements and coverage variations.

Denial Risk

Patient-initiated home OCT devices

Claims for patient-initiated home optical coherence tomography (home OCT) devices are considered investigational for all indications. Such claims are at risk for denial when billed as covered services.

Home OCT devices — investigational and not covered for all indications.

Background

Background context: glaucoma is an optic nerve degeneration often associated with elevated intraocular pressure but driven by multifactorial causes including vascular factors. Objective measurements of the retinal nerve fiber layer (RNFL) by modalities such as optical coherence tomography (OCT), confocal scanning laser ophthalmoscopy (CSLO), and scanning laser polarimetry (SLP) are established for diagnosis and management in covered indications, whereas emerging hemodynamic techniques and home OCT applications remain investigational.

Definitions

Confocal Scanning Laser Ophthalmoscopy (CSLO) — definition and example devices

DefinitionConfocal scanning laser ophthalmoscopy (CSLO) is an image acquisition technique that scans a laser across the retina with a detector to produce high-contrast, reproducible images used to estimate retinal nerve fiber layer (RNFL) thickness; does not require maximal mydriasis.

Common device exampleHeidelberg Retinal Tomograph (HRT) is a commonly cited CSLO device.

Key advantageSingle-spot illumination yields reproducible, high-contrast images suitable for quantitative RNFL estimation.

Scanning Laser Polarimetry (SLP) — definition and example devices

DefinitionScanning laser polarimetry (SLP) uses polarized laser light (typically a 780-nm diode) to detect RNFL birefringence and directly infer RNFL thickness by evaluating changes in the state of polarization of light emerging from the eye.

Revision History

2025-12-23administrative_update

Procedure code 92137 removed from the policy.

2025-09-04administrative_update

Benefit Variations section removed and Disclaimer updated.

2025-09-02administrative_update

Added ICD-10 diagnosis codes effective 10/01/2025.

Policy Summary

PayerCapital Bluecross

PolicyOphthalmologic techniques that evaluate the posterior eye segment

Policy CodePolicy MP 2.056

Change TypeNo material clinical or coverage changes in this revision

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionDocument comprehensive ophthalmologic exam findings (optic nerve assessment, visual fields, IOP) and the clinical indication to support medical necessity for RNFL analysis.

SourceLink

On This Page

Denial Risk

Investigational procedure denial

Procedures and codes listed as investigational in this policy are not covered and will be denied if billed as covered services. Examples include procedure codes 0198T and 0604T–0606T. Analysis of the optic nerve (RNFL) for indications other than the covered conditions listed in the policy is considered investigational and may be denied.

Investigational procedure codes (not covered): 0198T, 0604T, 0605T, 0606T.
RNFL analysis billed for indications other than glaucoma/glaucoma suspects, multiple sclerosis, increased intracranial pressure, optic neuritis, or optic nerve disorders may be denied as investigational.

Note

Not applicable / administrative notes

Not applicable content in this window: policy history documents administrative and coding updates but does not introduce additional provider documentation or prior authorization steps beyond those called out elsewhere in this section.

Policy history entries summarize coding and administrative changes; they do not alter clinical documentation requirements in this section.

Documentation Required

Documentation requirements for RNFL imaging

Providers should document a comprehensive ophthalmologic examination before relying on RNFL imaging for diagnosis or management decisions. Documentation should include assessment of the optic nerve, evaluation of visual fields, and measurement of intraocular pressure (IOP).

Document optic nerve assessment (ophthalmoscopy or stereophotography).
Document visual field evaluation.
Document intraocular pressure measurements.

Note

Coverage determined by member benefits

Coverage for listed procedures and services is determined by the member's benefit terms and the specific product. The presence of a code in the coding section does not itself denote coverage; providers must confirm eligibility and benefit limits prior to billing.

Coverage is subject to member benefit terms and product-specific limitations.
Not all services listed in coding sections are eligible for separate reimbursement.

Note

Policy identification

Reference this medical policy (MP 2.056) for full documentation requirements, coding guidance, coverage positions, and any applicable prior authorization information for ophthalmologic posterior segment evaluation techniques.

Policy identification: MP 2.056 — OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT.

Documentation Required

Standard clinical evaluation (comprehensive exam expected)

A standard clinical evaluation is expected prior to relying on RNFL imaging for diagnosis or management of glaucoma. That evaluation includes a comprehensive history and physical ophthalmologic exam, optic nerve assessment, visual field testing, and IOP measurement.

Standard clinical evaluation components: comprehensive exam, optic nerve assessment, visual fields, and IOP measurement.
RNFL imaging is an adjunct — do not use as the sole basis for diagnosis or management.

Note

Not specified in this section

Not specified in this section of the policy: this section does not add any additional provider actions beyond the documentation, coverage, investigational-denial, and product-variation guidance already provided above.

No additional provider actions specified within this section.

Denial Risk

Claims at risk for denial (other investigational indications)

Claims for RNFL analysis using scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), or OCT for indications other than the covered conditions listed in the policy may be denied as investigational. Similarly, measurement of ocular blood flow or pulsatile ocular blood flow is considered investigational for all indications and may be denied.

RNFL analysis covered indications: glaucoma or glaucoma suspects; multiple sclerosis; increased intracranial pressure; optic neuritis or optic nerve disorders.
Ocular blood flow measurements — investigational and not covered.

Common device example

GDx is a commonly used SLP device and includes a normative database and statistical software for comparison with age- and ethnicity-matched normals.

Practical noteImages can be obtained without pupil dilation and evaluation may be completed in about 10 minutes; modern instruments include enhanced and variable corneal compensation to account for corneal polarization.

Optical Coherence Tomography (OCT) — definition and modality notes

DefinitionOptical coherence tomography (OCT) uses near-infrared light to provide direct cross-sectional (2-dimensional) measurements of the RNFL, analogous in principle to B-mode ultrasound but using light instead of sound.

Modality notesIncludes spectral-domain (spectral) OCT and advanced analyses such as optic nerve head parameter analysis, macular parameter analysis, Doppler OCT, and OCT angiography (OCT-A).

Procedure noteOCT imaging typically requires dilation of the patient’s pupil and uses standard ophthalmic optics for retinal focusing.

Pulsatile Ocular Blood Flow / Ocular Blood Flow Measurements — definition and modality examples

DefinitionPulsatile ocular blood flow refers to the pulsatile variation in intraocular pressure resulting from choroidal blood inflow during cardiac systole; continuous IOP monitoring of this pulse can be converted to a volume-based measurement.

Measurement modalitiesTechniques to assess ocular blood flow include laser speckle flowgraphy, color Doppler imaging, Doppler Fourier domain OCT, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, and retinal functional imaging.

Clinical relevancePulsatile blood flow is primarily determined by choroidal vessels and is pertinent to glaucoma because the optic nerve receives substantial choroidal circulation.

CUP/DISC RATIO — definition

DefinitionCup-to-disc (cup/disc) ratio is the mathematical relationship between the horizontal or vertical diameter of the physiologic cup and the diameter of the optic disc.

Clinical useCup/disc ratio is used to describe optic nerve head morphology in glaucoma evaluation and monitoring.

Measurement contextOften assessed during comprehensive ophthalmologic exam and with optic nerve imaging techniques (CSLO, SLP, OCT).

DIABETIC RETINOPATHY — definition

DefinitionDiabetic retinopathy is a disorder of retinal blood vessels characterized by capillary microaneurysms, hemorrhage, exudates, and formation of new vessels and connective tissue.

Pathophysiology noteChanges reflect microvascular damage from diabetes and can be evaluated with posterior-segment imaging modalities.

RelevanceRetinal structural and hemodynamic assessments (e.g., OCT) are used in research and clinical evaluation of diabetic retinal disease.

INTRAOCULAR PRESSURE — definition

DefinitionIntraocular pressure (IOP) refers to the internal pressure of the eye, regulated by resistance to aqueous humor outflow through the trabecular meshwork.

Clinical relevanceElevated IOP is a major risk factor for glaucoma; IOP measurement is a routine part of glaucoma diagnosis and management.

Relation to pulsatile flowPulsatile ocular blood flow measurements derive from IOP variations during the cardiac cycle and can be converted into volume estimates.

OCT Angiography (OCT-A) / Laser Speckle Flowgraphy — definition and evidence mention

DefinitionOptical coherence tomography angiography (OCT-A) and laser speckle flowgraphy are imaging techniques that assess retinal and optic nerve head perfusion and microcirculation; they are discussed in the evidence base for glaucoma diagnosis and monitoring.

Evidence mentionMultiple cited studies evaluate OCT-A and laser speckle flowgraphy for glaucoma and optic nerve head perfusion, but overall clinical utility for improving health outcomes remains under investigation.

Comparative noteResearch includes comparisons between OCT-A and laser speckle flowgraphy as well as correlative studies with other blood-flow measurement methods.

Posterior-segment ophthalmologic diagnostic techniques — referenced modalities

ScopePosterior-segment ophthalmologic diagnostic techniques referenced include laser speckle flowgraphy, OCT angiography (OCT-A), colour Doppler imaging, and high-resolution ultrasonography.

ApplicationsThese modalities are used to evaluate blood flow, structural, and hemodynamic parameters of the posterior eye segment in research and select clinical contexts.

Evidence and utilityThe policy cites multiple studies assessing these techniques, though the document notes limited evidence that blood-flow measurements improve diagnostic accuracy or health outcomes in glaucoma management.

2025-05-16consensus_review

Consensus review with no change to policy stance; new references added.

2025-01-01administrative_update

Procedure code 92137 added (noted as added 12/11/2024; effective 01/01/2025).

2024-05-22consensus_review

Consensus review with no change to policy statement; references reviewed and updated; ICD-10 diagnosis code H40.2210 added.

2024-04-07consensus_review

Consensus review with no change to policy statement; references reviewed and updated; coding table format updated.

2023-05-11consensus_review

Consensus review with no change to policy statement; references reviewed and updated; no coding changes.

2022-04-07consensus_review

Consensus review with no change to policy statement; references reviewed and updated.

2021-09-16minor_review

Added the use of a patient-initiated home optical coherence tomography device as investigational; references and coding updated; FEP language updated.

2020-07-31major_review

Major review: added multiple sclerosis, increased intracranial pressure, optic neuritis, and optic nerve disorders to policy statement as potentially medically necessary; coding updated with ICD-10 codes H46-H47, G35, and G93.2; references updated; 'for Glaucoma' removed from policy title.

2020-04-21consensus_review

Consensus review with no change to policy statement; procedure codes 92201 and 92202 removed and references updated.

2020-01-01administrative_updateLatest

Administrative update: new procedure codes 92201 and 92202 added.