Currentpartners_health_managementPolicy CP.VP.31

Clinical Policy: Gonioscopy

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Defines coverage criteria and supporting diagnosis codes for gonioscopy procedures affecting members with relevant ophthalmic conditions; applies to providers submitting claims to Partners Health Management.

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Gonioscopy

Policy CodePolicy CP.VP.31

Change TypeNo material change

Effective Date

Last ReviewDec 1, 2024

Next Review DateDec 1, 2024

Key ActionInclude an applicable supporting ICD-10-CM diagnosis code from the policy on the claim and document medical necessity linking the code to clinical findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+Codes listed (section)

~70+Supporting ICD-10 codes

MultipleGlaucoma/angle codes

MultipleDiabetes-related codes

2019-2024

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Currentpartners_health_managementPolicy CP.VP.31

Clinical Policy: Gonioscopy

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Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Gonioscopy

Policy CodePolicy CP.VP.31

Change TypeNo material change

Effective Date

Last ReviewDec 1, 2024

Next Review DateDec 1, 2024

Key ActionInclude an applicable supporting ICD-10-CM diagnosis code from the policy on the claim and document medical necessity linking the code to clinical findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+Codes listed (section)

~70+Supporting ICD-10 codes

MultipleGlaucoma/angle codes

MultipleDiabetes-related codes

2019-2024

Coverage Criteria

Diagnosis-supported coverage

Covered when an applicable supporting ICD-10-CM diagnosis code is present on the claim and medical necessity is documented in accordance with the policy and member benefits.

ICD-10 diagnosis requirement: Claim includes one of the ICD-10-CM codes enumerated in the policy (e.g., H40.* series, H44.*, Q15.0, S05.* and the diabetes/retinopathy codes listed in chunks 18-42).N/A

See full code lists in the 'ICD-10-CM Codes that Support Coverage Criteria' sections; documentation should include the specific supporting diagnosis code and clinical justification.

No explicit exclusions for gonioscopy are listed in the cited policy sections. The provided document content enumerates ICD-10-CM diagnosis codes that support coverage but does not state any procedure-specific exclusion criteria in these chunks.

Coverage of gonioscopy is governed by the member's benefit documents and the terms, conditions, exclusions and limitations contained therein. The policy text emphasizes that coverage decisions and benefit administration are subject to the member's coverage documents and applicable state and federal requirements, but the referenced chunks do not list any specific exclusions for gonioscopy.

The cited policy sections do not specify any conditions or circumstances under which gonioscopy is expressly designated as not medically necessary. The document lists diagnosis codes that support coverage but does not include an explicit 'not medically necessary' list in these chunks.

No explicit 'not medically necessary' conditions for gonioscopy are stated in the provided document segments. The policy notes that providers must exercise clinical judgment and that the policy is a guide to medical necessity, but the cited chunks do not define specific exclusions or denial criteria labeled as 'not medically necessary.'

Coding and Diagnosis Codes

ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered

E11.3312	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye.
E11.3313	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye.
E11.3391	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral.
E11.3392	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye.
E11.3393	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye.
E11.3411	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye.
E11.3412	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye.
E11.3413	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral.
E11.3491	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye.
E11.3492	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye.

1–10 of 276

1/28

ICD-10-CM Codes Supporting CoverageICD-10Covered

H40.1433	Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage.
H40.151	Residual stage of open-angle glaucoma, right eye
H40.152	Residual stage of open-angle glaucoma, left eye
H40.153	Residual stage of open-angle glaucoma, bilateral
H40.211	Acute angle-closure glaucoma, right eye
H40.212	Acute angle-closure glaucoma, left eye
H40.213	Acute angle-closure glaucoma, bilateral
H40.2211	Chronic angle-closure glaucoma, right eye, mild stage
H40.2212	Chronic angle-closure glaucoma, right eye, moderate stage
H40.2213	Chronic angle-closure glaucoma, right eye, severe stage

1–10 of 103

1/11

inv-09: Policy review years

Original policy approval year2019

Most recent update12/2024

Template conversion notedConverted to new template 05/2020–06/2020

Annual review entries12/2020 (ref 01/2021), 12/2021 (ref 01/2022), 11/2022 (ref 12/2022), 11/2023 (ref 12/2023), 11/2024 (ref 12/2024)

Content change summaryUpdated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy (11/2023–12/2023)

Provider Actions and Billing Notes

Prior Authorization

Prior authorization

No prior authorization requirements are specified in the provided policy chunks.

Note

Prior authorization note — check member benefits and regulatory rules

Coverage decisions are governed by the member's benefit documents and applicable legal/regulatory requirements; the policy does not specify per‑procedure prior authorization rules in these chunks.

Coverage and administration are subject to terms, conditions, exclusions and limitations of the member's coverage documents.
State Medicaid provisions or Medicare NCD/LCDs take precedence where applicable.

Background

The policy provides an extensive list of ICD-10-CM diagnosis codes that support coverage for gonioscopy, covering a broad set of ophthalmic conditions. Included code groups span diabetic retinopathy subtypes (with laterality and macular edema designations), retinal vascular occlusions, inflammatory iris/ciliary body disorders (iridocyclitis, hypopyon), degenerative iris and ciliary body conditions, anatomical narrow angle (H40.031–H40.033), multiple glaucoma subtypes (open-angle, angle-closure, secondary glaucomas), hypotony and retained intraocular foreign body codes, congenital glaucoma (Q15.0), and traumatic eye injury codes (S05.*). Documentation should include the applicable supporting ICD-10-CM code from this list to establish medical necessity for the gonioscopy.

Definitions

Anatomical narrow angle (selected supporting ICD-10 codes for gonioscopy)

Anatomical narrow angle codesH40.031, H40.032, H40.033 (Anatomical narrow angle — right, left, bilateral)

Open-angle borderline codesH40.011, H40.012, H40.013, H40.021, H40.022, H40.023

Steroid responder / ocular hypertensionH40.041, H40.042, H40.043; H40.051, H40.052, H40.053

Primary angle-closure without glaucoma damageH40.061, H40.062, H40.063

Retinal vascular / microvascular abnormalitiesH35.073, H35.09

ICD-10-CM codes supporting coverage (selected groups)

Glaucoma-related groups

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Gonioscopy

Policy CodePolicy CP.VP.31

Change TypeNo material change

Effective Date

Last ReviewDec 1, 2024

Next Review DateDec 1, 2024

Key ActionInclude an applicable supporting ICD-10-CM diagnosis code from the policy on the claim and document medical necessity linking the code to clinical findings.

SourceLink

On This Page

Documentation Required

Include supporting ICD-10-CM diagnosis code(s) on claim

Include on the claim the applicable ICD-10-CM diagnosis code(s) from the policy's listed codes that support medical necessity for the gonioscopy.

Use a listed ICD-10-CM code that corresponds to the patient’s ophthalmic condition and laterality (see code lists in chunks 18–37).

Documentation Required

Document medical necessity and clinical rationale

Document medical necessity in the patient's record consistent with this clinical policy and the member's coverage; submission of a claim implies agreement with the policy terms and is subject to state and federal requirements.

Keep clinical findings and rationale in the medical record that link the chosen ICD-10-CM code(s) to the need for gonioscopy.
Be aware that providers are responsible for exercising professional medical judgment and maintaining documentation supporting the service.

Documentation Required

Diagnostic coding documentation

Documentation should include the ICD-10-CM diagnosis code(s) from the policy's listed codes that support medical necessity for the gonioscopy.

Select codes that reflect the condition and laterality (e.g., H40.031–H40.033 for anatomical narrow angle; diabetes- and retina-related codes in chunks 18–37).

Documentation Required

Medical necessity documentation required

Providers must document medical necessity consistent with this clinical policy and the member's coverage; claims submission implies agreement to policy terms and is subject to state and federal rules.

Maintain clinical notes that substantiate the indication for gonioscopy and reference the supporting ICD-10-CM code(s).

Denial Risk

Diagnosis-code support required — risk of denial if missing

Claims lacking one of the listed supporting ICD-10-CM diagnosis codes from this section may be at risk for denial.

Ensure the claim includes an applicable code from the policy's ICD-10-CM lists to reduce denial risk.

Denial Risk

Coverage subject to member benefit documents and regulatory requirements

Coverage and administration of benefits are subject to the member's coverage documents, state Medicaid rules, and applicable Medicare NCDs/LCDs; inconsistencies or noncompliance may result in denial.

Verify member-specific terms, exclusions, and limitations before assuming coverage.
For Medicaid and Medicare members, follow state Medicaid manual or applicable NCD/LCD guidance where it supersedes this policy.

Extensive H40.* series including H40.1111–H40.2233 and related subcodes (angle‑closure, secondary glaucomas, residual stages)

Hypotony and retained foreign body codesH44.411–H44.443; H44.601–H44.703

Congenital and trauma-related codesQ15.0 (congenital glaucoma); S05.* and S05.5*/S05.6* series (contusion/penetrating wounds of eyeball)

Sickle-cell and retinopathy codesH36.811–H36.823; H35.* series for retinal neovascularization and retinopathies

Scope noteDiagnosis codes listed in the policy (H40.*, H44.*, Q15.0, S05.*, etc.) are acceptable supporting diagnoses for gonioscopy when medical necessity is documented