Currentfallon_community_health_plan_incPolicy N/A

Anterior Segment Optical Coherence Tomography Clinical Coverage Criteria

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Defines Fallon Community Health Plan's coverage stance and medical necessity criteria for anterior segment OCT imaging of the eye for Fallon Health products and MassHealth ACO/Community Care members.

Policy Summary

Payerfallon_community_health_plan_inc

PolicyAnterior Segment Optical Coherence Tomography Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeOperational update — prior authorization removed

Effective DateJul 1, 2025

Last ReviewJun 23, 2026

Next Review DateJun 23, 2026

Key ActionDo not submit prior authorization requests for anterior segment OCT for dates of service on or after July 1, 2025.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

07/01/2025effective date for no prior authorization requirement

92132procedure code listed for AS-OCT

Sens 87% / Spec 84%AS-OCT diagnostic accuracy (median)

02/01/2017

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Currentfallon_community_health_plan_incPolicy N/A

Anterior Segment Optical Coherence Tomography Clinical Coverage Criteria

Customize your policy alerts

Sign up for all fallon_community_health_plan_inc policy alerts

Know when fallon_community_health_plan_inc releases new policies or updates existing guidance.

Monitor payer policy activity

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Defines Fallon Community Health Plan's coverage stance and medical necessity criteria for anterior segment OCT imaging of the eye for Fallon Health products and MassHealth ACO/Community Care members.

Policy Summary

Payerfallon_community_health_plan_inc

PolicyAnterior Segment Optical Coherence Tomography Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeOperational update — prior authorization removed

Effective DateJul 1, 2025

Last ReviewJun 23, 2026

Next Review DateJun 23, 2026

Key ActionDo not submit prior authorization requests for anterior segment OCT for dates of service on or after July 1, 2025.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

07/01/2025effective date for no prior authorization requirement

92132procedure code listed for AS-OCT

Sens 87% / Spec 84%AS-OCT diagnostic accuracy (median)

02/01/2017

policy origination date

Prior auth removedoperational change

Coverage Criteria

Medically necessary indications

Covered when ANY of the following indications are present (Fallon Health Clinical Coverage Criteria applicable to MassHealth ACO and Community Care members):

Medically necessary indications: Evaluate narrow angle, suspected narrow angle, mixed narrow and open angle glaucoma, and angle recession as all determined by gonioscopy.

Medically necessary indications: Determine the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction.

Medically necessary indications: Evaluate iris tumor.

Medically necessary indications: Evaluate corneal edema or opacity that precludes visualization or study of the anterior chamber.

Medically necessary indications: Calculate lens power for cataract patients who have undergone prior refractive surgery.

Medically necessary indications: Evaluate and plan treatment for patients with diseases affecting the cornea, iris, lens and other anterior segment structures.

Medically necessary indications: Provide additional information during the planning and follow-up for corneal, iris, cataract, glaucoma and other anterior segment surgeries.

Medicare variation / applicability

Medicare variation:

Medicare applicability: Medicare coverage criteria and the MAC LCD (SCODI L34380) govern AS-OCT; anterior segment OCT is not covered in the absence of a covered indication or for screening. The Plan's coverage criteria are not applicable where Medicare criteria fully establish coverage.

See LCD L34380.

Any use of anterior segment optical coherence tomography (AS-OCT) that is not among the medically necessary indications listed in this policy is not covered. This includes AS-OCT performed in relation to a non-covered eye procedure (for example, refractive surgery) and any other application outside the specified indications.

AS-OCT is explicitly not covered for screening or baseline documentation of a healthy eye; if performed as a preventive screen or routine baseline of an otherwise healthy eye it will be denied even when an otherwise-covered disease is incidentally identified.

Coverage for services described in this policy depends on the member’s specific benefit plan. Not all services referenced are covered for every Fallon Health product or employer group; providers should consult the member’s Evidence of Coverage or benefit documents to confirm applicability.

For Medicare members, Medicare coverage criteria and the applicable MAC LCD (SCODI L34380) govern AS-OCT; where Medicare fully establishes coverage, the Plan’s criteria do not apply.

AS-OCT is not covered for screening or as baseline documentation of a healthy eye. Procedures performed in the absence of a covered indication will be denied in accordance with Medicare guidance and this policy.

Providers must ensure clinical documentation supports a covered indication (for example, gonioscopy-confirmed narrow angle, prior refractive surgery requiring cataract IOL calculation, iris tumor, corneal opacity precluding anterior chamber visualization, or other listed indications) before submitting claims for AS-OCT.

Coding

Procedure codes (informational)CPT

92132

Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral

Provider Actions & Billing Guidance

Prior Authorization

Prior authorization no longer required

Effective for dates of service on or after July 1, 2025, anterior segment optical coherence tomography (AS‑OCT) does not require prior authorization.

Prior Authorization

Prior authorization removed (policy history)

Prior authorization requirement for AS‑OCT was removed effective for dates of service on or after 07/01/2025; this change is recorded in the policy history.

Note

Use AS‑OCT as an adjunct to gonioscopy

AS‑OCT is an adjunctive imaging modality to gonioscopy; gonioscopy remains the preferred diagnostic exam for angle assessment and should be performed when feasible.

Background

Anterior segment optical coherence tomography (AS-OCT) is a noninvasive, high-resolution imaging modality that produces cross-sectional images of anterior eye structures including the cornea, anterior chamber, iris and lens. It supplements clinical examination by providing objective visualization and measurements that aid diagnosis and surgical planning for anterior segment conditions.

AS-OCT is clinically useful for angle assessment in glaucoma (particularly when gonioscopy is limited or not possible), evaluation of corneal disease, assessment of iris lesions, planning cataract surgery in eyes with prior refractive surgery, and for preoperative and postoperative planning and follow-up of anterior segment surgeries.

Definitions

AS-OCT — definition and brief description

TermAS-OCT (Anterior segment optical coherence tomography)

DefinitionA noninvasive, non-contact imaging technique that produces high-resolution cross-sectional images of anterior eye structures (cornea, anterior chamber, iris, lens).

TechnologyDevices may use time-domain, spectral-domain, or swept-source methods; spectral and swept-source provide higher scan speed and resolution than time-domain.

Clinical applicationsImaging and assessment for glaucoma (angle evaluation), corneal and ocular surface disease, iris tumors, preoperative planning and postoperative monitoring for corneal and refractive surgery, and other anterior segment pathologies.

First commercial systems (historical)Zeiss Visante OCT and Slit-Lamp OCT (FDA-cleared 2005–2006).

Policy Summary

Payerfallon_community_health_plan_inc

PolicyAnterior Segment Optical Coherence Tomography Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeOperational update — prior authorization removed

Effective DateJul 1, 2025

Last ReviewJun 23, 2026

Next Review DateJun 23, 2026

Key ActionDo not submit prior authorization requests for anterior segment OCT for dates of service on or after July 1, 2025.

SourceLink

On This Page

Use AS‑OCT particularly when gonioscopy cannot be performed (e.g., corneal disease or poor patient cooperation).
Recognize that AS‑OCT cannot image the posterior iris or ciliary body well and may miss isolated peripheral anterior synechiae.

Step Therapy

Step therapy

No step therapy requirements for AS‑OCT are specified in this policy.

Documentation Required

Document a covered clinical indication

Clinical documentation must support one of the medically necessary indications listed in the policy to justify use of AS‑OCT.

Indications include: gonioscopy‑determined narrow angle or suspected narrow angle, planning for cataract extraction after prior refractive surgery, evaluation of iris tumor, corneal edema/opacity preventing visualization of the anterior chamber, lens power calculation after prior refractive surgery, and evaluation/ planning for anterior segment disease or surgery.

Billing Rule

Verify member benefit plan terms

Verify member‑specific benefit plan Evidence of Coverage for exclusions, limitations, or plan‑specific provisions because not all services in this policy apply to all products or employer groups.

If the benefit plan terms conflict with this policy, the member's benefit plan provisions govern.
State or federal mandates may supersede plan provisions for applicable fully insured or non‑ERISA plans.

Denial Risk

Denial triggers — absent covered indication or screening

AS‑OCT may be denied when performed in the absence of a covered indication or when used for screening or baseline documentation of a healthy eye; uses outside the outlined medically necessary indications or related to non‑covered procedures may be excluded.

AS‑OCT performed as a preventive screen or baseline study of a healthy eye is not covered.
AS‑OCT related to a non‑covered eye procedure (e.g., refractive surgery) may be excluded.

Denial Risk

Follow Medicare/MassHealth determinations — potential denial if criteria unmet

Coverage determinations for Medicare Advantage and NaviCare members will follow applicable Medicare NCDs/LCDs; if Medicare criteria do not establish coverage, Fallon Health may apply internal criteria. Fallon generally follows MassHealth guidelines for MassHealth members and may create criteria when absent—these jurisdictional rules can affect claim adjudication and lead to denial if Medicare/MassHealth criteria are not met.

For Medicare Advantage and NaviCare members, applicable Medicare LCD/NCD (e.g., SCODI L34380) govern AS‑OCT coverage—Plan criteria are not applicable where Medicare criteria are fully established.
For MassHealth members Fallon generally follows MassHealth Medical Necessity Guidelines; in their absence the Plan may create criteria.

Primary angle-closure disease (PACD) spectrum

Spectrum termsPrimary angle-closure suspect (PACS)

Spectrum termsPrimary angle closure (PAC)

Spectrum termsPrimary angle-closure glaucoma (PACG)

Spectrum termsAcute angle-closure crisis (AACC)

Related entitiesPlateau iris configuration and plateau iris syndrome (related anatomic variants described with PACD).

AS-OCT — alternate definitions / glossary entries

Alternate termAnterior segment optical coherence tomography (AS-OCT)

Alternate descriptionA non-contact OCT modality specifically configured to image the anterior chamber, angle, cornea and ocular surface for diagnostic and management purposes.

Device methodsMay utilize time-domain, spectral-domain, or swept-source acquisition; spectral and swept-source yield higher scan speed and resolution.

Use casesApplicable to conjunctival neoplasia, pterygium, scleritis, keratoconus, corneal dystrophies, infectious/noninfectious keratitis, and anterior segment imaging in glaucoma and surgical planning.