VISUAL FIELD TESTING
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Criteria for when visual field testing is medically necessary for members under the CHOC Children's Hospital Orange County Health Alliance eye care benefit; defines indications, documentation, coding, and frequency considerations for providers requesting authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria for Visual Field Testing
Glaucoma-related indications
Visual fields may be indicated for glaucoma suspicion, prior glaucoma diagnosis, any factor from Column A, or any two (2) factors from Column B.
Primary indications
- Column A — Optic nerve findings (any ONE): Any ONE optic nerve finding: segmental neuroretinal rim thinning; flame hemorrhage of the optic disc; bared circumlinear vessel/nerve fiber layer thin or wedge defect; atrophy/pallor; cup-to-disc (C/D) ratio > 0.6; or C/D ratio difference > 0.2 between eyes.
These findings constitute Column A.
- Column B — Any TWO factors: Any TWO of the listed intraocular pressure, risk factor, history, or patient/family report items (examples include: IOP thresholds as specified in policy, African American race, positive family history of glaucoma, visual field defect or constriction by patient or family report, history of blunt force ocular trauma/hyphema, angle recession, pseudoexfoliation of lens/heavily pigmented, prior treatment as glaucoma suspect due to injury).
When any two Column B factors are present the indication is met (see policy for specific IOP numeric thresholds and Column II variations).
General medical necessity indications
Visual field testing may be considered medically necessary when ANY of the following are substantiated by the medical record:
Each item corresponds to policy sections III.2.1–III.2.15.
Frequency and monitoring
Frequency must be commensurate with disease type/severity; additional exams (>1/year) require documentation.
Providers may be subject to retrospective quality review when services exceed established parameters; frequency for macular degeneration or central vision loss is dictated by stage/degree of risk.
This policy applies to visual field testing under the CHOC Children’s Hospital Orange County Health Alliance eye care benefit. There are no exclusions to this policy; all requests for visual field testing are assessed against the medical necessity criteria and requirements described in the policy and supporting documentation standards.
Services for visual field testing may be denied when documentation does not establish medical necessity or when records are incomplete and the provider fails to respond to requests for additional information. Repeated failure to submit requested documentation in a timely manner may result in referral to Quality. Providers and members will receive written notification of an adverse determination with appeal instructions and applicable timeframes.
Coding — CPT and Diagnosis Codes
| 92081 | Limited Examination - single stimulus level e.g., tangent screen, Autoplot, Arc perimeter and Octopus 3 or 7. |
| 92082 | Intermediate Examination - at least 2 isopters e.g., Goldmann perimeter, Semi-quantitative Suprathreshold screening program, Humphrey Suprathreshold automated test, Octopus program 33 and Visual Field automated screener. |
| 92083 | Comprehensive Examination - static determination of central 30° e.g., Quantitative automated threshold perimetry, Octopus program G-1, 32, or 42, Humphrey visual field analyzer threshold programs 30-2, 24-2, 30/60-2, 10-2 and Macular Red Quantitative Testing. |
| A18.53 | Tuberculous chorioretinitis. |
| A52.14 | Late syphilitic encephalitis. |
| A52.15 | Late syphilitic neuropathy. |
| A52.71 | Late syphilitic oculopathy. |
| B45.1 | Cerebral cryptococcosis. |
| B58.00 | Toxoplasma oculopathy - Toxoplasmosis, unspecified. |
| B58.09 | Toxoplasma oculopathy - Toxoplasmosis, unspecified. |
| C69.20 | Malignant neoplasm of retina. |
| C69.32 | Malignant neoplasm of choroid. |
| C69.60 | Malignant neoplasm of orbit. |
Provider Actions, Documentation, and Prior Authorization
Prior authorization required; include medical necessity documentation
Prior authorization is required per payer procedures; requests must include documentation establishing medical necessity as outlined in the policy and meet the stated indications and frequency rules.
- Include all criterion points and applicable Table information with the request.
- Ensure documentation is clear and legible and made available to Avēsis upon submission.
Provider responsibilities for documentation, frequency, and review
Providers must follow policy requirements for documentation, frequency, and physician attestation when ordering and performing visual field testing; ensure records meet the medical necessity criteria and are available on request.
- When two or more exams are performed per year, the medical record must establish medical necessity for the increased frequency.
- Providers may be subject to retrospective quality review if services exceed established parameters.
Required documentation and chart elements
Providers must submit clear, legible medical records documenting all criterion points and applicable table information; the chart must include physician signature, pertinent history and exam (including IOP), diagnostic testing, progress notes, test order with medical necessity, frequency, and test interpretation with dates, findings, progression/stable notation, diagnosis, and physician signature.
- Do not use 'white out'; 'black out' or scribble is not accepted. Single-line corrections require provider initials and date.
- Medical documentation must include date of test, date of interpretation, findings, progression/stable notation (unless baseline), diagnosis, and physician signature.
Denial triggers for incomplete or non‑supporting documentation
Requests will be denied when documentation does not establish medical necessity per the policy or when submitted documentation is incomplete and the provider fails to respond to requests for additional information.
- Repeated failure to submit documentation timely may result in referral to Quality.
- Provider and enrollee will receive written notification of adverse determination with appeal rights and instructions.
Background
Visual field testing is used to assist in the diagnosis and management of ocular and neurologic conditions that affect the visual pathway, and to track progression or stability of visual field loss. Confrontation visual field testing should be performed as an initial assessment prior to formal testing. The frequency and level of formal visual field testing should be commensurate with the type and severity of disease; when two or more examinations are performed in a year, the medical record must document the medical necessity for the increased frequency. Providers should remain informed of current standards of practice when ordering or performing visual field testing.
Definitions
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