Centene SCODI/OCT Coverage Update

Coverage Criteria

inv-01: Anterior SCODI - Medically Necessary

Covered when ANY one of the following anterior SCODI indications is present:

Anterior SCODI indications: Includes suspected glaucoma (optic nerve or nerve fiber layer defect suggestive of glaucoma such as enlarged or asymmetric cup‑to‑disc ratio, notching or narrowing of the neuroretinal rim, disc hemorrhage, or suspicious nerve fiber layer change), visual field abnormality consistent with glaucoma, elevated intraocular pressure >21 mm Hg, glaucoma associated with anatomic lens anomaly; glaucoma evaluation/monitoring for pigment dispersion, pseudoexfoliation, angle closure/narrowing, low‑tension pathology, secondary glaucoma (drug‑related, trauma, inflammation), corneal ulcer at risk of perforation, corneal edema/degeneration/transplant rejection or failure/infection, iris cyst/atrophy/degeneration/neoplasm, iridoschisis, anterior or posterior synechiae, goniosynechiae, iridodialysis, plateau iris syndrome, aphakia/subluxation or other anterior segment neoplasms or injuries.

Extracted from policy enumerated anterior indications (chunks 3,5,6).

inv-02: Posterior SCODI - Medically Necessary

Covered when ANY one of the following posterior SCODI indications is present:

Posterior SCODI indications: Includes posterior optic nerve and retinal indications such as optic nerve disorders (papilledema, coloboma, drusen, pseudopapilledema, Foster‑Kennedy syndrome, optic nerve sheath hemorrhage, hypoplasia), visual pathway or chiasm neoplasm/inflammatory/vascular disorders, visual field defects, diabetic eye disease/diabetic retinopathy, ocular injury, orbital conditions (cellulitis, myositis, tenonitis, cyst, edema, hemorrhage, osteomyelitis, periostitis, granuloma), orbital atrophy/deformity/enlargement/exostosis, exophthalmos/enophthalmos or globe displacement, choroidal neoplasm, focal chorioretinal inflammation, choroidal rupture/detachment, macular or choroidal scarring/atrophy/drusen/hole, degenerative myopia, retinal pigment epithelium detachment, retinal detachment/edema/ischemia/hemorrhage, vascular occlusion and other retinal vascular disorders, and related posterior segment conditions warranting imaging.

Compiled from enumerated posterior indications in chunks 5 and 6.

inv-03: CQ/HCQ baseline and annual SD-OCT

Covered when BOTH of the following are met for patients using chloroquine (CQ) or hydroxychloroquine (HCQ):

CQ/HCQ monitoring: (a) Spectral‑domain optical coherence tomography (SD‑OCT) is used (SD‑OCT specifically required for detection of early toxic retinal changes from CQ/HCQ); AND (b) the patient has systemic lupus erythematosus or rheumatoid arthritis and is receiving CQ or HCQ — the scan is used as a baseline prior to therapy and annually thereafter.baseline and annual

Policy requires SD‑OCT and documents baseline plus annual frequency; providers without SD‑OCT should refer to sites that have SD‑OCT (chunks 6,8,9).

inv-04: Not Medically Necessary

Not medically necessary for the following (examples listed in document):

Not medically necessary: Screening for glaucoma and advanced glaucomatous damage are listed as not medically necessary in this policy segment.

Policy explicitly lists screening for glaucoma and advanced glaucomatous damage as not medically necessary (chunk 6).

inv-05: Diagnosis-code-based coverage

Covered when billed with listed ICD-10-CM diagnosis codes

Diagnosis code match: CPT 92132 is supported when the member has an ICD‑10‑CM diagnosis from the anterior segment list; CPT 92133 is supported when the member has an ICD‑10‑CM diagnosis from the posterior segment/optic nerve list as enumerated in the policy.1 diagnosis code from respective list required

Lists of supporting ICD‑10‑CM codes are provided in the document (see chunks 18–34).

inv-06: Supported Diagnoses (partial)

Covered when ANY of the following ICD-10-CM diagnoses that support CPT 92132 or 92133 are present

Supported diagnoses: Presence of one of the listed ICD‑10‑CM diagnosis codes in the medical record that corresponds to the medical indications for CPT 92132 (anterior) or CPT 92133 (posterior/optic nerve), including the tumor, orbit, optic nerve, inflammatory, infectious, glaucoma and related codes shown in the policy.

Partial lists of supporting diagnoses are documented in chunks 36–39.

inv-07: Diagnosis-code supported coverage

Covered when the service is billed with one of the listed ICD-10-CM diagnosis codes corresponding to the CPT procedure (92132–92134).

Diagnosis match: Provider documents one of the ICD‑10‑CM codes listed in the policy section (chunks 54–73) as the medical indication for CPT 92132, 92133, or 92134.

Extensive code lists across chunks 54–73 support the CPT procedures; include one listed code on the claim.

inv-08: Diagnosis supports medical necessity for posterior segment imaging

Covered when an appropriate diabetes-related ICD-10-CM diagnosis from the listed codes is documented:

ICD-10 requirement: An ICD‑10‑CM diagnosis code from the provided list indicating diabetes‑related retinal disease (Type 1, Type 2, drug/chemical‑induced, or diabetes due to underlying condition) is documented on the claim or in the medical record to support posterior segment OCT (CPT 92132/92134).

Codes specify laterality and presence/absence/resolution of macular edema and complications (chunks 72,80,90).

inv-09: Diagnosis-based coverage criteria

Covered when billed with one of the supported ICD-10-CM diagnosis codes listed below for posterior segment/retina conditions

Supported diagnosis: Presence of any listed ICD‑10‑CM diagnosis code from chunks 90–109 that describe posterior segment, retinal, choroidal, orbital, or diabetic retinopathy conditions (e.g., proliferative and nonproliferative diabetic retinopathy codes, retinal detachment codes, choroidal disorders, vascular occlusions, macular disease).

See full enumerated list in chunks 90–109 for specific codes.

inv-10: Diagnosis-supported Coverage

Covered when the following ICD-10-CM diagnosis codes are submitted as the medical indication for CPT 92132 or CPT 92134:

ICD-10 match: Any one of the ICD‑10‑CM codes listed in chunks 108–127 must be present to support coverage for posterior segment OCT (CPT 92132/92134), including choroidal dystrophies, choroidal rupture/detachment, retinal detachment subcodes, vitreous disorders, degenerative myopia, hypotony, scotoma/visual field defect codes, and others enumerated.1 code

Refer to the policy code lists in chunks 108–127 for exact codes and laterality.

inv-11: Diagnosis-based coverage linkage

Covered when the submitted diagnosis is one of the ICD-10 codes listed as supporting coverage for the corresponding CPT procedure (examples shown):

ICD-10 diagnosis match: The member has an ICD‑10 diagnosis code listed in the policy’s 'ICD‑10 Diagnosis Codes that Support Coverage Criteria' for the requested CPT procedure (examples include vitreous prolapse/hemorrhage, vitreomacular adhesion, degenerative myopia variants, hypotony, scotoma/visual field defect codes, contusion/trauma codes, and others as enumerated across chunks 126–133).

This section provides examples and instructs use of the documented codes to support the billed CPT.

This policy states that screening for glaucoma is not medically necessary. The document explicitly lists screening for glaucoma and advanced glaucomatous damage among services considered not medically necessary under the SCODI/OCT policy framework.

Coverage for CPT procedures in this section is diagnosis-driven. Claims submitted without an ICD-10-CM diagnosis code from the lists provided for the corresponding CPT code (e.g., the anterior or posterior segment/retina code lists) are not supported by these diagnosis-based coverage criteria and may be at risk for denial.

The excerpted code lists in this document are partial. Not all possible diagnoses that could support SCODI procedures are included in this extract; the absence of a diagnosis from these excerpts alone does not determine coverage. Providers should consult the full policy lists and applicable plan documents when determining coverage.

While the document does not provide an explicit standalone statement for every omitted diagnosis, the policy and associated coding guidance imply that the absence of a matching diagnosis code on the claim may result in denial of coverage for the associated CPT procedure unless additional justification or an allowed diagnosis from the full policy is documented.

In the posterior segment/retina code windows shown, the extract focuses on diabetes-related retinal diagnoses to support CPT 92132/92134. There are no non-diabetic retinal diagnoses listed in this excerpt to support coverage for those CPTs; therefore, the absence of an appropriate listed diabetes-related ICD-10-CM retinal diagnosis in the claim or record may affect coverage for posterior segment imaging.

The policy presents extensive ICD-10-CM code lists in the referenced chunks. Codes that are not present in the enumerated ranges (for example, codes outside of chunks 108–127) are not represented here as supporting indications; absence of a listed code on the claim may lead to non-coverage or require additional clinical justification.

The document records a specific update removing vitreous membranes, strands and degeneration from the medical indications supporting posterior segment/retina SCODI (CPT 92134). This change is noted in the policy's revision history and therefore these diagnoses should no longer be used as standalone supporting indications for CPT 92134.

The policy lists examples of conditions and explicitly classifies certain uses as not medically necessary, including screening for glaucoma and evaluation of advanced glaucomatous damage. For glaucoma-related SCODI use, only the documented medical indications and supporting ICD-10-CM codes in the policy meet the coverage criteria.

This clinical policy is a guide to support medical necessity determinations. Coverage decisions are subject to the member's benefit documents and the plan’s terms, conditions, exclusions and limitations. Services that do not meet the policy criteria or the applicable plan documents may be considered not covered.

Coding and Billing

Covered CPT CodesCPTCovered

92132	Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
92133	Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
92134	Scanning computerized ophthalmic diagnostic imaging, posterior segment; with interpretation and report, unilateral or bilateral; retina

ICD-10 Codes — examples supporting CPT 92132 (anterior segment)ICD-10Covered

H21.243	Degeneration of pupillary margin, bilateral
H05.032	Periostitis of left orbit
H05.033	Periostitis of bilateral orbits
H05.041	Tenonitis of right orbit
H05.042	Tenonitis of left orbit
H05.043	Tenonitis of bilateral orbits
H05.112	Granuloma of left orbit
H05.113	Granuloma of bilateral orbits
H05.121	Orbital myositis, right orbit
H05.122	Orbital myositis, left orbit

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ICD-10 Codes — anterior segment (examples continued)ICD-10Covered

H05.312	Atrophy of left orbit
H05.313	Atrophy of bilateral orbits
H05.321	Deformity of right orbit due to bone disease
H05.331	Deformity of right orbit due to trauma or surgery
H05.332	Deformity of left orbit due to trauma or surgery
H05.333	Deformity of bilateral orbits due to trauma or surgery
H05.341	Enlargement of right orbit
H05.342	Enlargement of left orbit
H05.343	Enlargement of bilateral orbits
H05.351	Exostosis of right orbit

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ICD-10 Codes — glaucoma and related (examples)ICD-10Covered

H40.011	Angle with borderline findings, low risk, right eye open
H40.022	Open angle with borderline findings, high risk, left eye
H40.041	Steroid responder, right eye
H40.042	Steroid responder, left eye
H40.043	Steroid responder, bilateral
H40.051	Ocular hypertension, right eye
H40.052	Ocular hypertension, left eye
H40.053	Ocular hypertension, bilateral
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage

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ICD-10 Codes — foreign body / prosthetic device complications (examples)ICD-10Covered

H44.611	Retained (old) magnetic foreign body in anterior chamber, right eye
H44.612	Retained (old) magnetic foreign body in anterior chamber, left eye
H44.613	Retained (old) magnetic foreign body in anterior chamber, bilateral
H44.711	Retained (nonmagnetic) (old) foreign body in anterior chamber, right eye
H44.712	Retained (nonmagnetic) (old) foreign body in anterior chamber, left eye
H44.713	Retained (nonmagnetic) (old) foreign body in anterior chamber, bilateral
T85.21XA	Breakdown (mechanical) of intraocular lens, initial encounter
T85.21XD	Breakdown (mechanical) of intraocular lens, subsequent encounter
T85.21XS	Breakdown (mechanical) of intraocular lens, sequela
T85.22XA	Displacement of intraocular lens, initial encounter

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ICD-10 Codes — posterior segment / optic nerve / neoplasms (examples)ICD-10Covered

H05.811	Cyst of right orbit
H05.812	Cyst of left orbit
H05.813	Cyst of bilateral orbits
H40.1211	Low-tension glaucoma, right eye, mild stage
H40.1212	Low-tension glaucoma, right eye, moderate stage
H40.1213	Low-tension glaucoma, right eye, severe stage
H40.1321	Pigmentary glaucoma, left eye, mild stage
H40.1322	Pigmentary glaucoma, left eye, moderate stage
H40.1323	Pigmentary glaucoma, left eye, severe stage
H53.423	Scotoma of blind spot area, bilateral

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Covered CPT Codes — additional referencedCPTCovered

92132	Anterior segment imaging (see list of supporting ICD-10 codes)
92133	Posterior segment/optic nerve imaging (see list of supporting ICD-10 codes)

ICD-10-CM Diagnosis Codes that Support Coverage Criteria — selected diabetes & retina codes (partial list)ICD-10Covered

E08.3491	Diabetes due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492	... left eye
E08.3493	... bilateral
E08.3511	Diabetes due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512	... left eye
E08.3513	... bilateral
E08.3521	... traction retinal detachment involving macula, right eye
E08.3522	... left eye
E08.3523	... bilateral
E08.3531	... traction RD not involving macula, right eye

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Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for Spectral Domain Optical Coherence Tomography (SD‑OCT) services billed with CPT codes 92132, 92133, and 92134. Providers should verify and obtain any plan-level prior authorization or pre-notification requirements before performing SD‑OCT to avoid claim denials.

Affected CPTs: 92132, 92133, 92134
Verify prior authorization with the member’s Centene plan — coverage is subject to plan rules and benefit document terms

Documentation Required

Diagnosis Code Required on Claim and for Prior Authorization

Claims for CPT 92132, 92133, and 92134 must be supported by an appropriate ICD‑10‑CM diagnosis code that corresponds to the medical indication for the imaging. Documentation in the medical record must clearly show the supporting diagnosis.

Required supporting diagnosis: include an ICD‑10‑CM code from the lists provided in this policy that matches the clinical indication

Definitions

SCODI / OCT — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

DefinitionScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is a non-invasive, non-contact tomographic imaging technique producing high-resolution cross-sectional ocular images used to evaluate anterior and posterior segment diseases.

PurposeUsed for evaluation and treatment planning of cornea, iris, anterior chamber structures, and for assessment of retinal and choroidal layers, macular thickness, and vitreoretinal relationships.

ModalityEncompasses optical coherence tomography (OCT) technologies that generate reproducible cross-sectional ocular images for clinical assessment and surgical planning.

Noninvasive characteristicNon-contact imaging that provides high-resolution tomographic cross sections without intraocular instrumentation.

SD-OCT — Spectral-domain OCT (SD-OCT)

Definition

Background

Scanning computerized ophthalmic diagnostic imaging (SCODI / OCT) is a non-invasive, non-contact tomographic imaging method that produces high-resolution cross-sectional images of the anterior and posterior ocular structures. Spectral-domain OCT (SD-OCT) and other modalities provide improved axial resolution and are used clinically for anterior segment assessment, retinal and choroidal layer evaluation, macular thickness measurement, and detection of early toxic retinal changes such as those caused by chloroquine or hydroxychloroquine.

Revision History

2024-10diagnosis code updateLatest

Updated medically indicated diagnoses for posterior segment, retina (CPT 92134) to include additional ICD-10 codes related to retinal holes, breaks, and visual field defects (Approval Date 10/2024).

2024-07diagnosis code update

Updated medically indicated diagnoses for posterior segment, nerve (CPT 92133) to include primary optic atrophy (Approval Date 07/2024).

2023-12

OpenPayer

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI / OCT) Coverage Criteria