Local Coverage Determination (LCD)

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

L34431

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Contractor Information

LCD Information

Document Information

LCD ID
L34431
LCD Title
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34431
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 08/12/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
05/11/2017
Notice Period End Date
06/25/2017
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

42 CFR §410.32(a) indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80.6 Intraocular Photography and §80.9 Computer Enhanced Perimetry Part 2, §140.5 Laser Procedures



Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Background:

Scanning computerized ophthalmic diagnostic imaging (SCODI) is a noninvasive, noncontact imaging technique that produces high resolution images of ocular structures. These high resolution images are used to provide qualitative and quantitative data about the structural or physiologic properties of structures in the anterior and posterior segment that have been validated as clinically useful in monitoring progression, resolution, or response to treatment of various ocular conditions involving the retina and optic nerve over time.

Scanning computerized ophthalmic diagnostic imaging makes use of 3 distinct technologies to generate quantitative data:

• confocal laser scanning ophthalmoscopy (CSLO)
• scanning laser polarimetry (SLO)
• optical coherence tomography (OCT)

Examples of CSLO and SLO devices currently in use in clinical practice include the Heidelberg Laser Tomographic Scanner, Heidelberg Retinal Tomography (HRT), the GDx Nerve Fiber Analysis System, and the Retinal Thickness Analyzer (RTA). OCT is available from a number of manufacturers using 1 of 2 basic platforms, time domain (TD-OCT), such as the Visante anterior segment OCT, and the more widely used spectral, or Fourier, domain (SD/FD-OCT), such as the Spectralis, RTVue, Cirrus, and iVue.

Although these techniques are different, their objective is the same. Medicare will consider SCODI medically reasonable and necessary in evaluating disorders of the anterior and posterior segment as documented in this local coverage determination (LCD).

Posterior Segment

Glaucoma is the second leading cause of blindness worldwide, and a disease for which effective treatment to slow or prevent progressive vision loss is available. However, glaucoma is diagnostically challenging and the majority of patients are asymptomatic early in the course of disease when the disease is most amenable to treatment. At the time of diagnosis, approximately 10-39% of patients have irrecoverable vision loss from advanced glaucoma. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 40% of cases have pressures in the normal range, while many other patients with abnormally high pressures do not suffer glaucomatous damage. Structural changes in the optic disc may not appear until a significant functional deficit (visual field loss) has occurred.

There is no single diagnostic test that can be used exclusively to diagnose and monitor glaucoma. Diagnosis of glaucoma is made using an assemblage of data from tests that provide complementary assessments of the functional and structural status of the optic nerve. This often includes a comprehensive history and eye exam including visual acuity measurement, pupillary examination, intraocular pressure measurement, gonioscopy, anterior segment exam, fundoscopy, optic disc and retinal nerve fiber layer examination; and often confirmatory diagnostic tests including central corneal thickness measurement, visual field evaluation (preferably using automated perimetry), and quantitative imaging of the optic nerve head and retinal nerve fiber layer with stereoscopic disc photographs and SCODI.

SCODI allows for early detection of glaucomatous damage to the retinal nerve fiber layer or optic disc, and has demonstrated clinical utility in facilitating earlier diagnosis and treatment, as well as monitoring for progression and response to treatment.

SCODI also allows for differentiation and diagnosis of other disorders of the optic nerve, as well as monitoring for progressive optic neuropathy and response to treatment in a number of neuro-ophthalmologic conditions.

Retinal disorders are among the most common causes of severe and permanent vision loss. SCODI is an invaluable tool for the evaluation and treatment of patients with retinal disease, particularly when there is macular involvement. SCODI is able to detail the microscopic anatomy of the retina, subretina, and vitreoretinal interface and provide information that has demonstrated evidence of superiority to other available techniques in a number of clinical studies.

SCODI has demonstrated clinical utility in monitoring patients with retinal diseases for progression, which is critical for judging a response to or need for treatment of a number of retinal conditions.

SCODI has been validated for use in ongoing screening for drug-related ocular toxicity, due to its ability to detect early photoreceptor damage in patients taking certain high-risk drugs. The use of SCODI should be performed according to the most current recommended guidelines. The current recommendations for monitoring patients taking chloroquine or hydroxychloroquine include 1) a baseline exam within the 1st year of commencement which should include a SD-OCT if any macular abnormalities are present, and, 2) annual screening beginning at the 5th year of exposure in patients who are on a dose <5 mg/kg real weight and who lack other major risk factors. The presence of major risk factors or a dosage exceeding 5 mg/kg real weight may necessitate earlier and more frequent screening intervals.


Anterior Segment

There are numerous reports in the literature detailing the potential applications of anterior segment optical coherence tomography (AS-OCT and SD-OCT with anterior segment imaging capabilities) to image and provide measurements of anterior segment structures in a number of clinical situations. The current literature consists primarily of qualitative and quantitative imaging and detection capabilities, though there remains a lack of consensus on the sensitivity, specificity, and predictive value of AS-OCT in the vast majority of anterior segment applications and no endorsement of its use over gonioscopy or ultrasound biomicroscopy.

The strongest evidence in support of the clinical utility of AS-OCT lies in its ability to image the structures of the anterior chamber angle, particularly in narrow angles. Current recommended practice patterns by the American Academy of Ophthalmology endorse gonioscopy as the preferred means of performing evaluation of the anterior chamber angle. Although there remains insufficient evidence to endorse AS-OCT as a substitute for gonioscopy, AS-OCT is a recommended option in cases where angle closure is suspected, and the angle anatomy is not conducive to gonioscopic assessment.

Indications and Limitations:

SCODI – Anterior Segment


SCODI, anterior segment, with interpretation and report.

AS-OCT is considered reasonable and necessary when ordered for the evaluation of narrow angle, suspected narrow angle, and mixed mechanism glaucoma:

• In patients who are unable to undergo gonioscopy due to cognitive or physical limitations

• When anatomic features, corneal opacity, or corneal edema preclude gonioscopic visualization

Indications other than those stipulated in this LCD are considered investigational and are not covered.

SCODI is not covered for screening.

SCODI is not covered in the absence of an indication.

It is expected that no more than 2 AS-OCT tests per year would be indicated in evaluating patients with a diagnosis of angle closure suspect, narrow angles, angle closure, and mixed mechanism glaucoma without a significant change in clinical status.

It is expected that no more than 1  AS-OCT test per 3 years would be indicated in evaluating patients with all forms of open angle glaucoma including glaucoma suspect, ocular hypertension, secondary glaucoma, and congenital glaucoma.

SCODI – Optic Nerve

 SCODI, posterior segment, with interpretation and report, unilateral or bilateral nerve.

SCODI of the optic disc is considered reasonable and necessary when ordered to:

• Aid in the early diagnosis of glaucoma and monitor for progression and response to treatment

• Monitor glaucoma suspect patients for evidence of glaucomatous change

• Detect further loss of optic nerve or retinal nerve fiber layer tissue to aid in monitoring for progression in advanced optic nerve damage and advanced visual field loss

• Differentiate when there is a discrepancy between the clinical appearance of the optic nerve and the visual field

• Provide additional information to facilitate diagnosis and management when visual field results are insufficient or cannot be performed due to visual, mental, physical, or age limitations of the patient

• Differentiate causes of other optic nerve disorders when a diagnosis is in doubt

• Aid in the diagnosis and management of other optic nerve disorders and neuro-ophthalmologic diseases involving changes in the optic nerve head and retinal nerve fiber layer

SCODI is not covered when used for screening.

SCODI is not covered in the absence of an indication.

It is expected that no more than 1 SCODI test per year would be indicated in monitoring patients with glaucoma suspect without a significant change in clinical status.

It is expected that no more than 2 SCODI tests per year would be indicated in monitoring patients with progressive optic neuropathies, including glaucoma (mild, moderate, severe, and indeterminate) without a significant change in clinical status.

Advancements in SCODI technologies have increased the utility of these devices in both the diagnosis of glaucoma and detection of glaucomatous progression. Hardware and software limitations can impact the reliability of these tests in more advanced cases of glaucoma, particularly once the floor effect is reached, whereby the ability to discern and measure thickness of the remaining neural tissue limits the ability to detect progression. The use of SCODI in advanced glaucoma is covered, provided the hardware and software utilized continues to provide clinically meaningful measurements that allow for the detection of progression.

SCODI – Retina

SCODI, posterior segment, with interpretation and report, unilateral or bilateral. 

SCODI of the retina is considered reasonable and necessary when ordered to:

• Aid in the diagnosis and management of retinal conditions which involve changes in the subretinal, intraretinal, and vitreoretinal relationships

• Monitor for progression or resolution of conditions in order to determine the need for or response to treatment

• Monitor for evidence of ocular toxicity in patients taking high risk drugs with a known potential for causing toxic retinopathy

SCODI is not covered when used for screening.

SCODI is not covered in the absence of an indication.

SCODI should only be performed at clinically reasonable intervals (i.e., consistent with a noted change in clinical status or after sufficient time has elapsed to assess for progression or response to treatment). It is generally expected that conditions requiring more aggressive treatment and monitoring due to changing clinical status or treatment interventions will generally not require SCODI testing more than 1 per month.

Current recommendations for monitoring patients taking chloroquine or hydroxychloroquine, who are on a dose <5 mg/kg real weight, who lack other major risk factors are recommended to undergo screening beginning at the 5th year of exposure and annually thereafter. The presence of major risk factors or a dosage exceeding 5 mg/kg real weight may necessitate earlier and more frequent screening intervals.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history and physical examination, along with interpretation and reports of all pertinent diagnostic tests or procedures.

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

Sources of Information
N/A
Bibliography

American Academy of Ophthalmology. Preferred practice pattern: primary open-angle glaucoma. San Francisco:American Academy of Ophthalmology. 2015.

American Academy of Ophthalmology. Preferred Practice Pattern Primary Open-Angle Glaucoma Suspect. 2015.

American Academy of Ophthalmology. Preferred Practice Pattern Primary Angle Closure. 2015.

Baskaran M, Iyer JV, Narayanaswamy AK, et al. Anterior segment imaging predicts incident gonioscopic angle closure. Ophthalmology. 2015;122(12):2380-2384.

Belghith A, Medeiros FA, Bowd C, et al. Structural change can be detected in advanced glaucoma eyes. Invest Ophthalmol Vis Sci. 2016;57(9):511-518.

Bowd C, Zangwill LM, Weinreb RN, Medeiros FA and Belghith A. Estimating optical coherence tomography structural measurement floors to improve detection of progression in advanced glaucoma. Am J Ophthalmol. 2017;175:37-44.

de Moraes CG, Liebmann JM, Medeiros FA, Weinreb RN. Management of advanced glaucoma: characterization and monitoring. Surv of Ophthalmol. 2016;61(5):597-615.

Mansberger SL, Demirel S. Early detection of glaucomatous visual field loss:why, what, where, and how. Ophthalmol Clin N Am. 2005;18(3):365-373.

Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF, et al. Recommendation on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). Ophthalmology. 2016;123(6):1386-1394.

McDonald HR, Williams GA, Scott IU, et al. Laser scanning imaging for macular disease. A report by the American Academy of Ophthalmology. Ophthalmology. 2007;114(6):1221-1228.

Nongpiur ME, Haaland BA, Friedman DS, et al. Classification algorithms based on anterior segment optical coherence tomography measurements for detection of angle closure. Ophthalmology. 2013;120(1):48-54.

Qin B, Francis BA, Li Y, et al. Anterior chamber angle measurements using Schwalbe's line with high resolution fourier-domain optical coherence tomography. J Glaucoma. 2013;22(9):684-8.

Sakata LM, Lavanya R, Friedman DS, et al. Comparison of gonioscopy and anterior segment ocular coherence tomography in detecting angle closure in different quadrants of the anterior chamber angle. Ophthalmology. 2008;115(5):769-774.

Smith SD, Singh K, Lin SC, et al. Evaluation of the anterior chamber angle in glaucoma Ophthalmology. 2013; 120(10):1985-1997.

Tay EL, Yong VK, Lim BA, et al. Agreement of angle closure assessments between gonioscopy, anterior segment optical coherence tomography and spectral domain optical coherence tomography. Int J Ophthalmol. 2015;8(2):342-346.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
08/12/2021 R20

Under CMS National Coverage Policy combined the verbiage from the 2 CMS Internet-Only Manual, Pub 100-03 citations from the Medicare National Coverage Determinations Manual, Chapter 1. Acronyms were inserted and defined where appropriate throughout the LCD. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/24/2019 R19

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56825 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
09/05/2019 R18

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56825 article. Under Coding Information: Bill Type Codes removed code 021x as it was inadvertently added with Revision 17.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/08/2019 R17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56825 article and removed from the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

  • Provider Education/Guidance
05/16/2018 R16

Under Coverage Indications, Limitations and/or Medical Necessity – Posterior Segment added the verbiage “<5 mg/kg real weight and who lack other major risk factors. The presence of major risk factors or a dosage exceeding 5 mg/kg real weight may necessitate earlier and more frequent screening intervals” to the last paragraph and last sentence as this verbiage was inadvertently omitted. Under Indications and Limitations - SCODI – Retina added the verbiage “<5 mg/kg real weight who lack other major risk factors are recommended to undergo screening beginning at the 5th year of exposure and annually thereafter. The presence of major risk factors or a dosage exceeding 5 mg/kg real weight may necessitate earlier and more frequent screening intervals” to the last sentence as this verbiage was inadvertently omitted.

 

  • Provider Education/Guidance
05/16/2018 R15

Under ICD-10 Codes that Support Medical Necessity Group 4: Paragraph 92133, Group 4: Codes added H40.1424. This revision is due to a reconsideration request. Under Bibliography added two authors “Medeiros FA and Belghith A” to the 6th cited reference to now read “Bowd C, Zangwill LM, Weinreb RN, Medeiros FA and Belghith A. Estimating optical coherence tomography structural measurement floors to improve detection of progression in advanced glaucoma. Am J Ophthalmol. 2017;175:37-44”.

 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
  • Reconsideration Request
02/26/2018 R14 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R13 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R12

Under ICD-10 Codes That Support Medical Necessity Group 3: Codes added ICD-10 codes H44.2A1, H44.2A2, H44.2A3, H44.2B1, H44.2B2, H44.2B3, H44.2C1, H44.2C2, H44.2C3, H44.2D1, H44.2D2, H44.2D3, H44.2E1, H44.2E2 and H44.2E3. This revision is due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/26/2017 R11

Formatted the references under the Sources of Information and Basis for Decision section.

  • Other
06/26/2017 R10 Under Coverage Indications, Limitations and/or Medical Necessity- revised verbiage to remove, erroneous descriptions of mild, moderate, and severe glaucoma. Updated to allow for SCODI coverage in eyes with advanced glaucoma provided the hardware and software utilized continues to provide clinically meaningful measurements that allow for the detection of progression. Updated to allow for same day visual field and SCODI testing when both are indicated. Updated to reflect the need for increased SCODI frequency to up to 1/month for various retinal indications provided there is documentation to support the frequent intervals as clinically reasonable and medically necessary. Updated to include coverage for AS-OCT in order to evaluate the anterior chamber angle in patients who are unable to undergo gonioscopy due to mental or physical limitations; when anatomic features, corneal opacity, or corneal edema preclude gonioscopic visualization. Under ICD-10 Codes that Support Medical Necessity Group 1 and Group 2: Paragraphs- added "The use of one code from both Group 1 and Group2 should be selected when billing for 92132. In the event the coding does not adequately describe the specific patient circumstances precluding gonioscopic assessment of the anterior chamber angle which necessitate anterior segment OCT, supporting documentation should be clearly documented in the medical record”. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes – added codes A18.59, H17.01, H17.02, H17.03, H17.11, H17.12, H17.13, H17.811, H17.812, H17.813, H17.821, H17.822, H17.823, H17.89, H17.9, H18.11, H18.12, H18.13, H18.20, H18.211, H18.212, H18.213, H18.221, H18.222, H18.223, H18.231, H18.232, H18.233. Removed unspecified eye and stage unspecified ICD-10 codes. Under Sources of Information and Basis for Decision – updated the references to include the most up to date information.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/03/2016 R9 Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes H35.361, H35.362, H35.363, H44.21, H44.22, H44.23, H53.131, H53.132, H53.133, H59.031, H59.032, H59.033, L93.0, M05.9, M06.9 and Z79.899. This revision is effective on or after 10/1/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
  • Reconsideration Request
10/03/2016 R8 Under ICD-10 Codes That Support Medical Necessity: Group 1 added E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E08.37X1, E08.37X2, E08.37X3, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.3591, E09.3592, E09.3593, E09.37X1, E09.37X2, E09.37X3, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E10.37X1, E10.37X2, E10.37X3, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E11.37X1, E11.37X2, E11.37X3, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.3591, E13.3592, E13.3593, E13.37X1, E13.37X2, E13.37X3, H34.8110, H34.8111, H34.8112, H34.8120, H34.8121, H34.8122, H34.8130, H34.8131, H34.8132, H34.8310, H34.8311, H34.8312, H34.8320, H34.8321, H34.8322, H34.8330, H34.8331, H34.8332, H35.3110, H35.3111, H35.3112, H35.3113, H35.3114, H35.3120, H35.3121, H35.3122, H35.3123, H35.3124, H35.3130, H35.3131, H35.3132, H35.3133, H35.3134, H35.3210, H35.3211, H35.3212, H35.3213, H35.3220, H35.3221, H35.3222, H35.3223, H35.3230, H35.3231, H35.3232, H35.3233, H40.1110, H40.1111, H40.1112, H40.1113, H40.1114, H40.1120, H40.1121, H40.1122, H40.1123, H40.1124, H40.1130, H40.1131, H40.1132, H40.1133, and H40.1134. Under ICD-10 Codes That Support Medical Necessity: Group 1 deleted E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.321, E10.329,E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, H34.811, H34.812, H34.813, H34.831, H34.832, H34.833, H35.31, H35.32, H40.11X1, H40.11X2, H40.11X3, and H40.11X4. This revision is due to the Annual ICD-10 Code Update which becomes effective October 1, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/03/2016 R7 Under Associated Contract Numbers added the contractor numbers for Part B as the Part A LCD was made an A/B MAC LCD.
  • Provider Education/Guidance
  • Other
05/12/2016 R6 Under Revision Effective Date the date for revision 5 should be 05/12/2016.
  • Provider Education/Guidance
03/10/2016 R5 Under Coverage Indications, Limitations and/or Medical Necessity – Abstract transferred the second paragraph from Indications and Limitations – Retinal Disorders to first paragraph of Abstract. Redundant second paragraph under Abstract replaced with reworded first paragraph from Retinal Disorders. Under Indications and Limitations – Glaucoma reworded all paragraphs. Under Glaucoma Suspect or Mild Damage – Visual Field defined “VF”. Under Moderate Glaucomatous Damage reworded first paragraph. Under Advanced Glaucomatous Damage reworded first paragraph and the last sentence of this section. Under Sources of Information and Basis for Decision removed “H” from Pinkerton.


  • Provider Education/Guidance
  • Other
03/10/2016 R4 Under Bill Type Codes deleted the bill types as per the previous revision history these codes were to be deleted. Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes H43.11, H43.12, H43.13, H43.811, H43.812, and H43.813.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R2 Under CMS National Coverage Policy deleted the following reference: CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.1 Computed Tomography. Under Coverage Indications, Limitations and/or Medical Necessity –Abstract the last sentence in the second paragraph was reworded for clarification. Under Coverage Indications, Limitations and/or Medical Necessity –Moderate Glaucomatous Damage added “that” to the fourth sentence of the first paragraph and reworded the last sentence of the second paragraph for clarification. Under Associated Information-Documentation Requirements corrected the title of the cited LCD section, added “and” to the last sentence of the first paragraph and deleted “the” from the second paragraph. Under Sources of Information and Basis for Decision author names and the supplement number were added and “et al” was deleted for the following: Bayer A, Harasymowycz P, Henderer JD, Steinmann WG, Spaeth GL. Validity of a new disk grading scale for estimating glaucomatous damage: correlation with visual field damage. Am J Ophthalmol. 2002;133(6):758-763. The volume number cited was a typographical error and was corrected to now read: Mansberger SL, Demirel S. Early detection of glaucomatous visual field loss: why, what, where, and how. Ophthalmol Clin N Am. 2005;18(3):365-373.
  • Provider Education/Guidance
  • Typographical Error
  • Other
10/01/2015 R1 Under CMS National Coverage Policy the Internet-Only Manual Section Titles were added for Intraocular Photography, Computer Enhanced Perimetry, Laser Procedures and Computer Tomography.
Under Coverage Indications, Limitations and/or Medical Necessity made some grammatical corrections.
Under Revenue Codes added Revenue code 0450 Emergency Room.
Under Associated Information removed the verbiage “results of pertinent diagnostic tests or procedures” and completed the sentence to read “This documentation includes, but is not limited to, relevant medical history and physical examination along with interpretation and reports of all pertinent diagnostic tests or procedures”.
Under Sources of information and Basis for Decision made correction to citations to meet AMA criteria.
  • Public Education/Guidance
  • Other (Annual validation)

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Keywords

  • Scanning Computerized Ophthalmic Diagnostic Imaging
  • SCODI
  • Ophthalmic

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