CurrentCentenePolicy CP.VP.63

Clinical Policy: Visual Field Testing

Medical necessity and coding guidance for performing and reporting visual field testing for members of Centene-affiliated health plans; describes indications, non-covered situations, and CPT/ICD-10 coding referenced. Applies to providers submitting claims to Centene/Envolve Vision.

Policy Summary

PayerCentene

PolicyClinical Policy: Visual Field Testing

Policy CodePolicy CP.VP.63

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport visual field exams with CPT 92081/92082/92083 and document an appropriate listed ICD-10 diagnosis to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Visual field CPT codes listed

dozensDiagnosis codes supporting coverage

2/yearRepeated testing restrictions

20Document chunks in this extract

YesDiabetes-related codes included

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inv-01: Indications / Initial testing

Covered when ANY of the following indications are present:

Indications for medical necessity: A. Malpositioning of the upper eyelid, including dermatochalasis, blepharochalasis, blepharoptosis, brow ptosis or injury B. Glaucoma or glaucoma suspect C. Diabetic and/or hypertensive retinopathy D. Macular pathology, including degeneration E. Functional assessment of the optic nerve (eg papilledema, coloboma, drusen, pallor, pseudopapilledema, Foster-Kennedy syndrome, optic nerve sheath hemorrhage, hypoplasia) F. Intracranial hemorrhage, mass or increased intracranial pressure G. Occlusion and/or stenosis of cerebral/precerebral arteries, transient cerebral ischemia or giant cell arteritis H. Retinal vascular occlusion, changes in vascular appearance, exudative retinopathy, micro-aneurysms, retinal neovascularization, vasculitis, or telangiectasias I. Retinal dystrophies, tears, thinning, schisis, edema, ischemia, hemorrhage or detachment J. Symptoms or diagnosis of neoplasm of brain including the optic chiasm, cranial nerves, pituitary and pineal glands, or craniopharyngeal duct K. Visual field defects identified on gross visual field screening L. Use of high risk medication (eg Plaquenil) M. Focal chorioretinal inflammation N. Choroidal rupture or detachment O. Degenerative myopia P. Retinal pigment epithelium detachment Q. Retinal or choroidal neovascularization R. Buphthalmos S. Ocular injury

List taken verbatim from policy

inv-02: Not Medically Necessary

Not medically necessary when ANY of the following apply:

Not medically necessary: A. Repeated testing for a stable, diagnosed condition (listed above) B. Repeated testing exceeding twice per year for controlled glaucoma C. Pretreatment for retinal detachment D. Diagnosis and/or management of cataracts

Listed non-covered indications

inv-03: Diagnosis-based coverage linkage

Covered when diagnosis codes indicating visual field defects, blindness, optic pathway injury, cerebrovascular disease, or traumatic brain/ocular injury are present (as listed).

diagnosis listed: Member has one or more of the ICD-10-CM diagnosis codes enumerated in this document segment (eg H53.*, H54.*, H55.*, H57.*, I60-I68.*, I63.*, S04.*, S05.*, S06.*, Q*, M31.*, etc.).at least 1 listed diagnosis

The policy text in these chunks is a code list; full medical necessity criteria likely appear elsewhere in the policy.

inv-04: Medical Necessity Guidance

Policy provides medical necessity guidance for visual field testing and lists medically indicated diagnoses including traumatic brain injuries and other ocular/neurologic conditions.

General: Visual field testing is guided by medical necessity determinations per the clinical policy and applicable coverage documents.

Providers should use this policy with state Medicaid or Medicare NCD/LCDs as applicable.

The policy explicitly lists certain uses of visual field testing that are not medically necessary. Specifically, visual field testing for pretreatment for retinal detachment and for the diagnosis and/or management of cataracts are identified as non-covered indications in the referenced policy language.

This document segment provides an enumerated listing of ICD-10 diagnosis codes relevant to visual field testing but does not include procedural coverage criteria or explicit procedural exclusions. Use the diagnosis code list to support clinical justification; procedural coverage rules appear in other policy sections.

No explicit exclusions are stated within this excerpt of the clinical policy. The chunks in this section present diagnosis code listings and related descriptions without identifying additional excluded clinical scenarios.

Coverage determinations pursuant to this clinical policy are subject to the terms, conditions, exclusions and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy or contract). Specific exclusions are not listed in the excerpt provided; plan-level benefit language and applicable state/federal requirements govern final coverage decisions.

The policy identifies limits on repeated testing. Claims for repeated visual field testing for a stable, diagnosed condition may be considered not medically necessary. For glaucoma, repeated testing that exceeds twice per year for controlled glaucoma is specifically noted as not medically necessary and may place claims at risk for denial.

Within these chunks there are no explicit statements labeling additional services as not medically necessary. The content is a diagnostic code listing and does not state further non-coverage determinations.

This alternate document segment contains comprehensive ICD-10 code descriptions and does not include explicit not medically necessary declarations in the provided excerpt.

The excerpt for this section does not enumerate explicit Not Medically Necessary conditions. It provides policy context about medical necessity guidance and states that coverage decisions rely on plan documents and applicable law.

Provider documentation, billing, and authorization guidance

Documentation Required

Diagnosis codes and match for authorization

Diagnosis codes listed in this segment are ICD-10 codes only; ensure the member's diagnosis code(s) match one of the listed ICD-10-CM codes to support coverage determinations.

Diagnosis code list only: ICD-10 codes shown in the clinical policy (e.g., E09.3291, G37.0, H40.1111, H53.16, H54.x series, etc.).
Diagnosis match for authorization: Claims should include an appropriate supporting ICD-10-CM diagnosis from the listed codes to reduce risk of denial.

Prior Authorization

Prior authorization guidance

No explicit prior authorization requirements are specified in the provided excerpt. Follow the member's Health Plan documents and any Health Plan-level administrative policies to determine if prior authorization is required.

Prior authorization: not specified in this segment.
Prior authorization not stated in this segment — check plan documents for any Health Plan-specific prior authorization rules.

Documentation Required

Documentation and required diagnostic support

Documentation in the excerpt is limited to listing ICD-10 diagnosis codes; there is no detailed documentation checklist provided. Providers must document clinical findings that support the presence of one of the listed diagnoses and follow applicable NCDs/LCDs and Health Plan documentation requirements.

Documentation: diagnosis codes for claims — include the appropriate ICD-10 code(s) on claims and in the medical record.
This segment is a listing of ICD-10 diagnosis codes referenced by the policy; documentation requirements are not specified here.
Required diagnostic documentation: clinical documentation should support the diagnosis (e.g., visual disturbance, optic nerve dysfunction, glaucoma, retinal disease) used to justify testing.

Denial Risk

Denial risks and contractual coverage limits

Claims lacking an appropriate supporting ICD-10-CM diagnosis from the listed codes or requests for repeated testing outside the stated frequency may be at risk for denial. Coverage remains subject to the terms of the member's contract and applicable law.

Denial risk: missing indication — absence of an appropriate listed ICD-10 diagnosis may lead to denial.
Repeated testing denial risk — repeated visual field testing for a stable condition or exceeding twice/year for controlled glaucoma may be denied.
Coverage subject to contract and law — check the member's coverage documents for exclusions, limitations, and state/federal requirements.

Definitions and test descriptions

Visual field test — definition and brief description

DefinitionA visual field test is a painless examination that determines a patient’s visible field of view by mapping central and peripheral vision.

PurposeDetects and localizes defects along the visual pathway to evaluate ocular, optic nerve, and neurological disease.

Common modalityStandard automated white-on-white perimetry (eg, SITA strategies) is the most commonly performed clinical test for visual fields.

Gross visual field testing — confrontation and computerized screening

What it includesGross visual field testing refers to confrontation testing and computerized screening field assessments used in routine ophthalmologic exams.

Reporting noteThese gross screening assessments are part of general ophthalmological services and should not be reported separately.

RoleUseful for initial screening but less sensitive/specific than standard automated perimetry for documenting defects or progression.

Diabetic retinopathy ICD-10 codes — reference to E08E13 series codes included in policy

UseThese diabetic retinopathy codes support medical necessity for visual field testing when retinopathy/macular disease is present.

Neurologic diagnoses — examples including MS, neuromyelitis optica, epilepsy

ExamplesNeurologic diagnoses referenced include G35 (multiple sclerosis) and G36.0 (neuromyelitis optica).

Epilepsy codesA range of epilepsy codes (G40.*) are listed that may relate to visual pathway evaluation and visual field testing.

ContextNeurologic disorders listed support visual field testing for optic pathway or cortical visual deficits.

Diagnosis codes relevant to visual field testing — ICD-10 diagnosis list reference

ContentThe policy provides a contiguous listing of ICD-10-CM diagnosis codes relevant to visual field testing to support claims and medical necessity determinations.

Examples of code blocksIncluded code blocks span neurologic (G*), vascular (I6*/I63*), traumatic (S04*/S06*), visual disturbance and scotoma codes (H53.*/H54.*), and many H-series ophthalmic diagnoses.

Intended useProviders should cite an appropriate listed ICD-10-CM diagnosis when requesting authorization or submitting claims for visual field testing.

H40 series — glaucoma-related codes summary

ScopeH40 series codes in the policy cover a range of glaucoma-related diagnoses including open-angle glaucoma, ocular hypertension, primary angle-closure, low-tension glaucoma and staging (mild/moderate/severe).

ExamplesSpecific codes include H40.1111 (primary open-angle glaucoma, right eye, mild) and H40.1211 (low-tension glaucoma, right eye, mild).

RelevanceGlaucoma-related H40 codes are listed as medically indicated diagnoses supporting visual field testing for diagnosis and monitoring.

H35 series — macular and retinal conditions summary

ScopeH35 series codes cover macular and retinal conditions including nonexudative and exudative age-related macular degeneration, macular holes/cysts, drusen, retinal edema and toxic maculopathy.

RelevanceMacular/retinal H35 diagnoses are included as indications supporting visual field testing when retinal pathology affects visual function.

ICD-10 diagnoses list — contiguous listing referenced in the clinical policy

NatureThe policy references a contiguous ICD-10-CM diagnosis list covering ophthalmic, neurologic, vascular, traumatic and congenital conditions relevant to visual field testing.

Provider useProviders should select the most specific listed diagnosis code to support medical necessity for visual field testing on claims or authorizations.

Scotoma — definition and H53.* codes referenced

ExamplesSpecific scotoma/blindness codes include H53.411 (central scotoma, right eye) and H53.421 (scotoma of blind spot area, right eye).

RelevanceScotoma codes support medical necessity for formal visual field testing to document and quantify localized field defects.

Traumatic brain injury (TBI) — spectrum of injury with S06.* codes included

ScopeTraumatic brain injury (TBI) in the policy is represented by multiple S06.* codes covering concussion, diffuse injury, cerebral edema and traumatic hemorrhage across encounter types.

RelevanceTBI diagnoses listed indicate neurologic causes of visual field deficits and support medical necessity for perimetric testing when present.

Automated perimetry / visual field testing — clinical test supported by AAO assessments and practice patterns

Test modalityAutomated perimetry (standard white-on-white) is the primary clinical test for evaluating the visual field; alternative modalities (SITA strategies, short-wavelength automated perimetry, FDT/Matrix) are discussed in references and background.

Guideline supportAAO technology assessments and practice pattern guidelines are cited in references recommending automated perimetry for clinical evaluation and monitoring.

Clinical roleAutomated perimetry is used to detect, quantify, and monitor visual field defects attributable to ocular, optic nerve, and neurologic disease.

Document maintenance and references

2019-12annual_review

Annual review completed (12/2019) documenting policy maintenance activity.

2020-07format_change

Policy converted to new template (07/2020).

2020-10format_approval

Conversion to new template approved (10/2020).

2020-12annual_review

Annual review completed and approved (12/2020).

2021-12annual_review_and_update

Annual review with updated references and expanded medical indications to include traumatic brain injuries, hypotony, corneal opacities, and lagophthalmos (12/2021).

2022-11coverage_update

Annual review updated coverage criteria to include new ICD-10 codes for traumatic brain injuries (11/2022).

2022-12coverage_update_approval

Approval of coverage criteria updates adding new ICD-10 codes for traumatic brain injuries (12/2022).

2023-11medical_indications_update

Updated medically indicated diagnoses to include new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura (11/2023).

2023-12update_approvalLatest

Approval of 11/2023 updates adding new ICD-10 codes for extraocular muscle entrapment and chronic migraine with aura (12/2023).

Prior authorization and utilization control for visual field testing are determined by medical necessity per the clinical policy and by the member's benefit documents. Report visual field examinations with CPT codes 92081, 92082, or 92083 including interpretation and report, and ensure documentation supports one of the listed qualifying diagnoses. The policy is a guide to medical necessity but does not replace plan-level prior authorization rules; check the Health Plan or benefit contract for prior authorization requirements.

C71.1	Malignant neoplasm of frontal lobe
C71.2	Malignant neoplasm of temporal lobe
C71.3	Malignant neoplasm of parietal lobe
C71.4	Malignant neoplasm of occipital lobe
C71.5	Malignant neoplasm of cerebral ventricle
C71.6	Malignant neoplasm of cerebellum
C71.7	Malignant neoplasm of brain stem
C71.8	Malignant neoplasm of overlapping sites of brain
C72.21	Malignant neoplasm of right olfactory nerve
C72.22	Malignant neoplasm of left olfactory nerve

OpenPayer

Clinical Policy: Visual Field Testing

Coverage criteria for visual field testing

CPT and ICD-10 codes referenced

Provider documentation, billing, and authorization guidance

Background and scope

Definitions and test descriptions

Document maintenance and references

92081	Visual field examination, unilateral or bilateral, with interpretation and report; limited
92082	Visual field examination, unilateral or bilateral, with interpretation and report; intermediate
92083	Visual field examination, unilateral or bilateral, with interpretation and report; extended