CurrentCentenePolicy CP.VP.63

Visual Field Testing

Defines medical necessity criteria, non-covered indications, coding guidance, and supporting ICD-10 codes for visual field testing (standard automated and gross screening) for Centene/Envolve plans. Part 1 includes policy statements, background, CPT codes for visual field exams, and an extensive list of ICD-10 diagnosis codes that support coverage.

Policy Summary

PayerCentene

PolicyVisual Field Testing

Policy CodePolicy CP.VP.63

Change TypeRevised (annual updates + template conversion)

Effective Date

Next Review Date

Key ActionProviders should document one of the medically indicated ICD-10 diagnoses listed in this policy when requesting/performing visual field testing to support coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Updated medically indicated diagnoses to include new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura.

Annual review; Updated coverage criteria to include new ICD-10 codes for traumatic brain injuries.

Annual Review; Updated medical indications to include traumatic brain injuries, hypotony, corneal opacities and lagophthalmos.

Converted to new template

3Visual field CPT codes listed

17+ICD-10 codes listed (partial in Part 1)

2Not medically necessary scenarios called out

ICD-10 codes listed in this part

AnnualReview frequency

Coverage Summary

Scope: Visual Field Testing — policy defines medical necessity criteria, non-covered indications, coding guidance, and supporting ICD-10 codes for visual field testing (standard automated and gross screening) for Centene/Envolve plans.

Payer/Policy stance: This policy is issued for health plans affiliated with Centene Corporation and Envolve Vision, Inc. and the coverage stance is covered_with_criteria (visual field testing is medically necessary when criteria are met; some indications are not medically necessary).

Status / Review: Policy Reference CP.VP.63. Last Review Date: 11/2023; Approval/Update noted 12/2023. The document states it is current and provides guidance to assist coverage decisions but is not a guarantee of payment.

Medical-Necessity Criteria

Medically necessary indications

Visual field testing is medically necessary for the following indications:

ALL of the following

ONE OF
- Malpositioning of the upper eyelid, including dermatochalasis, blepharochalasis, blepharoptosis, brow ptosis or injury
- Glaucoma or glaucoma suspect
- Diabetic and/or hypertensive retinopathy
- Macular pathology, including degeneration
- Functional assessment of the optic nerve in any of the following conditions: papilledema, coloboma, drusen, pallor, pseudopapilledema, Foster-Kennedy syndrome, optic nerve sheath hemorrhage, or hypoplasia
- Intracranial hemorrhage, mass or increased intracranial pressure
- Occlusion and/or stenosis of cerebral/precerebral arteries, transient cerebral ischemia or giant cell arteritis
- Retinal vascular occlusion (central retinal artery, partial retinal artery, retinal artery branch, central retinal vein, tributary retinal vein), changes in vascular appearance, exudative retinopathy, retinal micro-aneurysms, retinal neovascularization, vasculitis, or telangiectasias
- Retinal dystrophies, tears, thinning, schisis edema, ischemia, hemorrhage or detachment
- Symptoms or diagnosis of neoplasm of brain including the optic chiasm, cranial nerves, pituitary and pineal glands, or craniopharyngeal duct
- Visual field defects identified on gross visual field screening
- Use of high risk medication (e.g. Plaquenil)
- Focal chorioretinal inflammation
- Choroidal rupture or detachment
- Degenerative myopia
- Retinal pigment epithelium detachment
- Retinal or choroidal neovascularization
- Buphthalmos
- Ocular injury

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Not medically necessary

Visual field testing is not medically necessary for the following indications:

ALL of the following

Repeated testing for a stable, diagnosed condition (above)
Repeated testing exceeding twice per year for controlled glaucoma
Pretreatment for retinal detachment
Diagnosis and/or management of cataracts

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Medically Indicated Diagnoses (ICD-10 codes listed)

Visual field testing is indicated for the following diagnoses (ICD-10 codes):

ONE OF

I65.8 - Occlusion and stenosis of other precerebral arteries
I66.01 - Occlusion and stenosis of right middle cerebral artery
I66.02 - Occlusion and stenosis of left middle cerebral artery
I66.03 - Occlusion and stenosis of bilateral middle cerebral arteries
I66.11 - Occlusion and stenosis of right anterior cerebral artery

Coding

Covered CPT codes for visual field examinationsCPTCovered

92081	Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent).
92082	Visual field examination, unilateral or bilateral, with interpretation and report: intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33).
92083	Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

ICD-10-CM diagnosis codes that support coverage criteria (partial list from Part 1)ICD-10Covered

A18.53	Tuberculous chorioretinitis
A52.15	Late syphilitic neuropathy
B58.01	Toxoplasma chorioretinitis
C69.01	Malignant neoplasm of right conjunctiva
C69.02	Malignant neoplasm of left conjunctiva
C69.11	Malignant neoplasm of right cornea
C69.12	Malignant neoplasm of left cornea
C69.21	Malignant neoplasm of right retina
C69.22	Malignant neoplasm of left retina
C69.31	Malignant neoplasm of right choroid

1–10 of 57

1/6

Medically Indicated ICD-10 Codes (listed in this part)ICD-10Covered

I65.8	Occlusion and stenosis of other precerebral arteries
I66.01	Occlusion and stenosis of right middle cerebral artery
I66.02	Occlusion and stenosis of left middle cerebral artery
I66.03	Occlusion and stenosis of bilateral middle cerebral arteries
I66.11	Occlusion and stenosis of right anterior cerebral artery
I66.12	Occlusion and stenosis of left anterior cerebral artery
I66.13	Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21	Occlusion and stenosis of right posterior cerebral artery
I66.22	Occlusion and stenosis of left posterior cerebral artery
I66.23	Occlusion and stenosis of bilateral posterior cerebral arteries

1–10 of 53

1/6

Other ICD-10 / Administrative encounter codes includedICD-10

T37.2X5A	Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter
T37.2X5D	Adverse effect of antimalarials and drugs acting on other blood protozoa, subsequent encounter
T37.2X5S	Adverse effect of antimalarials and drugs acting on other blood protozoa, sequela
Z03.89	Encounter for observation for other suspected diseases and conditions ruled out
Z04.71	Encounter for examination and observation following alleged adult physical abuse
Z04.72	Encounter for examination and observation following alleged child physical abuse
Z09	Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z79.899	Other long term (current) drug therapy

Provider Actions

Billing Rule

Report visual field exams with appropriate CPT

Report visual field examinations using the appropriate CPT code for the examination type; use 92081 for limited, 92082 for intermediate, and 92083 for extended visual field exams — each reported with interpretation and report.

92081
92082
92083

Denial Risk

Frequency limitations for stable or controlled conditions

Repeated testing for a stable, previously diagnosed condition and repeated testing exceeding twice per year for controlled glaucoma are considered not medically necessary and may be denied.

Background

Background / Purpose: Visual field testing is a painless assessment that maps a patient’s central and peripheral vision to detect areas of reduced or absent vision. The pattern and location of visual field loss help localize pathology anywhere along the visual pathway from the retina, through the optic nerves and chiasm, to the visual cortex.

Common testing modalities: The policy describes that standard white-on-white automated perimetry is the most commonly performed test, with the Swedish Interactive Threshold Algorithm (SITA) largely replacing full-threshold strategies. It also notes frequency-doubling technology (FDT) / Matrix perimetry and short-wavelength automated perimetry have been evaluated extensively — short-wavelength perimetry can detect loss earlier (reported sensitivity ~88% and specificity ~92%) but is lengthy and sensitive to media opacities; FDT shows high sensitivity/specificity for moderate/advanced glaucoma and is a useful, rapid screening tool.

Service reporting note: The policy explicitly states that gross visual field testing (e.g., confrontation testing) and computerized screening field assessments are part of general ophthalmological services and should not be reported separately.

Evidence / References: References include American Academy of Ophthalmology perimetry reports and Preferred Practice Pattern guidelines (selected reports 2001–2020) and Mayfield Clinic materials cited in the policy.

Revision History

11/2023 (approval 12/2023)policy_revisionLatest

Updated medically indicated diagnoses to include new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura.

11/2022 (approval 12/2022)annual_review

Annual review; updated coverage criteria to include new ICD-10 codes for traumatic brain injuries.

12/2021 (approval 01/2022)annual_review

Annual review; updated medical indications to include traumatic brain injuries, hypotony, corneal opacities and lagophthalmos.

Policy Summary

PayerCentene

PolicyVisual Field Testing

Policy CodePolicy CP.VP.63

Change TypeRevised (annual updates + template conversion)

Effective Date

Next Review Date

Key ActionProviders should document one of the medically indicated ICD-10 diagnoses listed in this policy when requesting/performing visual field testing to support coverage decisions.

SourceLink

On This Page

ref_id__do_not_use_field_visible__ref_b1_1

title__do_not_use_field_visible__Not medically necessary

title__final__Not medically necessary

I66.12 - Occlusion and stenosis of left anterior cerebral artery

I66.13 - Occlusion and stenosis of bilateral anterior cerebral arteries

I66.21 - Occlusion and stenosis of right posterior cerebral artery

I66.22 - Occlusion and stenosis of left posterior cerebral artery

I66.23 - Occlusion and stenosis of bilateral posterior cerebral arteries

I66.3 - Occlusion and stenosis of cerebellar arteries

I67.1 - Cerebral aneurysm, nonruptured

I67.2 - Cerebral atherosclerosis

I67.4 - Hypertensive encephalopathy

I67.5 - Moyamoya disease

I67.6 - Nonpyogenic thrombosis of intracranial nervous system

I67.81 - Acute cerebrovascular insufficiency

I67.82 - Cerebral ischemia

I67.83 - Posterior reversible encephalopathy syndrome

I67.841 - Reversible cerebrovascular vasoconstriction syndrome

I67.850 - Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

I68.0 - Cerebral amyloid angiopathy

M31.5 - Giant cell arteritis with polymyalgia rheumatica

M31.6 - Other giant cell arteritis

Q10.0 - Congenital ptosis

Q14.0 - Congenital malformation of vitreous humor

Q14.1 - Congenital malformation of retina

Q14.2 - Congenital malformation of optic disc

Q14.3 - Congenital malformation of choroid

Q15.0 - Congenital glaucoma

Q85.01 - Neurofibromatosis, type 1

Q85.03 - Schwannomatosis

S04.011A - Injury of optic nerve, right eye, initial encounter

S04.011D - Injury of optic nerve, right eye, subsequent encounter

S04.011S - Injury of optic nerve, right eye, sequela

S04.012A - Injury of optic nerve, left eye, initial encounter

S04.012D - Injury of optic nerve, left eye, subsequent encounter

S04.012S - Injury of optic nerve, left eye, sequela

S04.02XA - Injury of optic chiasm, initial encounter

S04.02XD - Injury of optic chiasm, subsequent encounter

S04.02XS - Injury of optic chiasm, sequela

S04.031A - Injury of optic tract and pathways, right eye, initial encounter

S04.031D - Injury of optic tract and pathways, right eye, subsequent encounter

S04.031S - Injury of optic tract and pathways, right eye, sequela

S04.032A - Injury of optic tract and pathways, left eye, initial encounter

S04.032D - Injury of optic tract and pathways, left eye, subsequent encounter

S04.032S - Injury of optic tract and pathways, left eye, sequela

S04.041A - Injury of visual cortex, right eye, initial encounter

S04.041D - Injury of visual cortex, right eye, subsequent encounter

S04.041S - Injury of visual cortex, right eye, sequela

S04.042A - Injury of visual cortex, left eye, initial encounter

S04.042D - Injury of visual cortex, left eye, subsequent encounter

S04.042S - Injury of visual cortex, left eye, sequela

S04.11XA - Injury of oculomotor nerve right side initial encounter

S04.11XD - Injury of oculomotor nerve right side subsequent encounter

S04.11XS - Injury of oculomotor nerve right side sequela

S04.12XA - Injury of oculomotor nerve left side initial encounter

S04.12XD - Injury of oculomotor nerve left side subsequent encounter

S04.12XS - Injury of oculomotor nerve left side sequela

S05.11XA - Contusion of eyeball and orbital tissues, right eye, initial encounter

S05.11XD - Contusion of eyeball and orbital tissues, right eye, subsequent encounter

S05.11XS - Contusion of eyeball and orbital tissues, right eye, sequela

S05.12XA - Contusion of eyeball and orbital tissues, left eye, initial encounter

S05.12XD - Contusion of eyeball and orbital tissues, left eye, subsequent encounter

S05.12XS - Contusion of eyeball and orbital tissues, left eye, sequela

S06.0X0A - Concussion without loss of consciousness, initial encounter

S06.0X0D - Concussion without loss of consciousness, subsequent encounter

S06.0X0S - Concussion without loss of consciousness, sequela

S06.0X1A - Concussion with loss of consciousness of 30 minutes or less, initial encounter

S06.0X1D - Concussion with loss of consciousness of 30 minutes or less, subsequent encounter

S06.0X1S - Concussion with loss of consciousness of 30 minutes or less, sequela

S06.0X9A - Concussion with loss of consciousness of unspecified duration, initial encounter

S06.0X9D - Concussion with loss of consciousness of unspecified duration, subsequent encounter

S06.0X9S - Concussion with loss of consciousness of unspecified duration, sequela

S06.1X0A - Traumatic cerebral edema without loss of consciousness, initial encounter

S06.1X1A - Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter

S06.1X2A - Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.1X3A - Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.1X4A - Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.1X5A - Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.1X6A - Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.1X9A - Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter

S06.2XAA - Diffuse traumatic brain injury with loss of consciousness status unknown, initial encounter

S06.2X0A - Diffuse traumatic brain injury without loss of consciousness, initial encounter

S06.2X1A - Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter

S06.2X2A - Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.2X3A - Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.2X4A - Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.2X5A - Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels, initial encounter

S06.2X6A - Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.2X9A - Diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter

S06.30AA - Unspecified focal traumatic brain injury with loss of consciousness status unknown, initial encounter

S06.300A - Unspecified focal traumatic brain injury without loss of consciousness, initial encounter

S06.301A - Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter

S06.302A - Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.303A - Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.304A - Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.305A - Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.306A - Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.309A - Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, initial encounter

S06.31AA - Contusion and laceration of right cerebrum with loss of consciousness status unknown, initial encounter

S06.310A - Contusion and laceration of right cerebrum without loss of consciousness, initial encounter

S06.311A - Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, initial encounter

S06.312A - Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.313A - Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.314A - Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.315A - Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

Repeated testing for a stable, diagnosed condition — not medically necessary

More than 2 tests per year for controlled glaucoma — not medically necessary

Documentation Required

Use listed ICD-10 codes to support medical necessity

Document one of the medically indicated ICD-10 diagnoses listed in this policy when requesting or performing visual field testing to support medical necessity determinations.

Reference the ICD-10 diagnosis code groups provided in the Coding / ICD-10 sections of the policy (examples and long lists start in the "ICD-10-CM Diagnosis Codes that Support Coverage Criteria" section).

07/2020 conversion (approval 10/2020)format_conversion

Converted to new template.