Local Coverage Determination (LCD)

Ophthalmic Angiography (Fluorescein and Indocyanine Green)

L34426

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11201 - MAC A	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11301 - MAC A	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11401 - MAC A	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11501 - MAC A	J - M	North Carolina
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

LCD Information

Document Information

LCD ID
L34426

LCD Title
Ophthalmic Angiography (Fluorescein and Indocyanine Green)

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL34426

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 07/15/2021

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
09/08/2016

Notice Period End Date
10/23/2016

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(14) defines other than physician services.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical exams.

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).

42 CFR §410.74 defines physician assistants' services.

42 CFR §410.75 defines nurse practitioners' services.

42 CFR §410.76 defines clinical nurse specialists' services.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80.2 Photodynamic Therapy, §80.2.1 Ocular Photodynamic Therapy (OPT) - Effective April 3, 2013, §80.3 Photosensitive Drugs and §80.3 Verteporfin - Effective April 3, 2013

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Fluorescein

Fluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular disorders and monitoring treatment of conditions amenable to laser photocoagulation.

The dye is injected intravenously and serial photographs are taken through the pupil. While morphological characteristics alone may be pathognomonic of certain disease states, the timing of appearance of the dye in the choroid, in the central retinal artery and in the filling (or otherwise) of the quadrants have diagnostic implications.

Indocyanine Green

Indocyanine green (ICG) dye is injected intravenously into the patient to highlight the vessels in the retina and the deeper tissue layer of the choroid. Under infrared light, ICG fluoresces allowing the choroidal vessels to be visualized through the retinal pigment epithelium or in the presence of retinal or vitreous hemorrhage that would otherwise obscure visualization. ICG is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration (AMD). It is also useful in the evaluation of feeder vessels, choroidal leakages in the late phase and ruptures of the pigment epithelium.

Indications:

Fluorescein

Fluorescein angiography with interpretation is medically necessary as an adjunct to the diagnosis of chorioretinal vascular abnormalities especially relating to choroid neovascularization, noninfective vasculitis and AMD. It may also be appropriate in evaluating intraocular tumors, visual loss in systemic disease, acute exudative inflammations, such as toxoplasmosis and optic disc edema. Medical necessity for such angiography would generally be in the context of a changing clinical picture. Fluorescein angiography may be useful in diabetic retinopathy in identifying ischemia and neovascularization, locating microaneurysms and defining macular edema.

Fluorescein angiography following treatment, for example, of choroidal neovascularization (CNV) is necessary to monitor for recurrence or to detect additional treatable disease. Usually this is performed on the basis of a change in the clinical picture similar to the way it is employed prior to treatment. However, fluorescein angiography may be performed following treatment without clinical change in order to detect occult lesions. This will occur most often in CNV and very rarely in other diseases.

Indocyanine Green

ICG may be a valuable diagnostic adjunct to fluorescein angiography in the evaluation of the following conditions:

Retinal neovascularization
Choroid neovascularization
Serous detachment of retinal pigment epithelium
Hemorrhagic detachment of retinal pigment epithelium
Retinal hemorrhage

Limitations:

Fluorescein

Studies performed for screening will be denied by Medicare as not medically necessary.

Fluorescein angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner.

If excluded by State law, optometrists may not be reimbursed for fluorescein angiography.

Fluorescein angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each eye.

Indocyanine Green

ICG angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner.

If excluded by State law, optometrists may not be reimbursed for ICG angiography.

ICG is formulated with iodine and should not be used on patients who are allergic to iodine.

ICG for the evaluation of patients with background diabetic retinopathy is not considered to be a medically necessary service.

ICG angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each eye.

Studies performed for screening will be denied by Medicare as not medically necessary.

Other Comments:

Limitation of liability and refund requirements apply when denials are based on medical necessity. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facilities (CORFs), references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Section CMS National Coverage Policy).

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Contact for Comments on Proposed LCD

Coding Information

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for fluorescein and ICG angiography as it is covered by Medicare. (See Coverage Indications, Limitations, and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.

Copies of fluorescein and ICG angiograms (photographic or digital) must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves.

The medical record should include documentation of 1 of the following when ICG angiography is performed:

Evidence of ill-defined subretinal neovascular membrane or suspicious membrane on previous fluorescein angiography
Retinal pigment epithelium (RPE) does not show subretinal neovascular membrane on current fluorescein angiography
Presence of subretinal hemorrhage or hemorrhagic RPE. A fluorescein angiography need not have been done previously.

Evidence of medical necessity must be documented in the medical record for each eye.

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

Utilization Guidelines

Fluorescein angiography is considered medically necessary no more than 9 times per eye in 365 days. Claims exceeding this frequency will be suspended and reviewed for medical necessity.

ICG angiography is considered medically necessary no more than 9 times per eye in 365 days. Claims exceeding this frequency will be suspended and reviewed for medical necessity.

Fluorescein angiography performed within 30 days of ICG angiography will be denied as not medically necessary, unless there is documentation in the patient's medical record of co-existing diseases, such as AMD or diabetes.

Sources of Information
N/A

Bibliography

Altan-Yaycioglu R, Akova YA, Akca S, Yilmaz G. Inflammation of the posterior uvea: Findings on fundus fluorescein and indocyanine green angiography. Ocul Immunol Inflamm. 2006;14(3):171-179.

Arevalo JF, Fuenmayor-Rivera D, Giral AE, Murcia E. Indocyanine green videoangiography of multifocal Cryptococcus neoformans choroiditis in a patient with acquired immunodeficiency syndrome. Retina. 2001;21(5):537-541.

Bakri SJ, Sculley L, Singh AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13.

Battaglia Parodi M, Da Pozzo S, Ravalico G. Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration. Eye. 2004;18(7):685-690.

Bennett TJ. Fundamentals of fluorescein angiography. Ophthalmic Photographers' Society Web Site. Accessed June 3, 2021.

Bischoff PM, Helbig H, Niederberger HJ, Török B. Simultaneous ICG- and fluorescein-angiography for fundus examination. Klin Monatsbl Augenheilkd. 2000;216(2):120-125.

Bischoff PM, Niederberger HJ, Török B, Speiser P. Simultaneous indocyanine green and fluorescein angiography. Retina. 1995;15(2):91-99.

Bottoni FG, Aandekerk AL, Deutman AF. Clinical application of digital indocyanine green videoangiography in senile macular degeneration. Graefe's Arch Clin Exp Ophthalmol. 1994;232(8):458-468.

Bouchenaki N, Cimino L, Auer C, Tao Tran V, Herbort CP. Assessment and classification of choroidal vasculitis in posterior uveitis using indocyanine green angiography. Klin Monatsbl Augenheilkd. 2002;219(4):243-249.

Coscas G, Coscas F, Soubrane G. Monitoring the patient after treatment: Angiographic aspects of recurrence and indications for retreatment. J Fr Ophtalmol. 2004;27(1):81-92.

Dyer DS, Brant AM, Schachat AP, Bressler SB, Bressler NM. Angiographic features and outcome of questionable recurrent choroidal neovascularization. Am J Ophthalmol. 1995;120(4):497-505.

Guyer DR, Yannuzzi LA, Slakter JS, Sorenson JA, Spaide RF, Freund KB, et al. Principles of indocyanine-green angiography. In: Guyer DR, Yannuzzi LA, Chang S, Shields JA, Green WR, eds. Retina-Vitreous-Macula. Philadelphia:W.B.Saunders;1999:39-46.

Helbig H, Niederberger H, Valmaggia C, Bischoff P. Simultaneous fluorescein and indocyanine green angiography for exudative macular degeneration. Klin Monatsbl Augenheilkd. 2005;222(3):202-205.

Jampol LM. Hypertension and visual outcome in the macular photocoagulation study. Arch Ophthalmol. 1991;109(6):789-790.

Khairallah M, Ben Yahia S, Attia S, et al. Indocyanine green angiographic features in multifocal chorioretinitis associated with West Nile virus infection. Retina. 2006;26(3):358-359.

Kramer M, Mimouni K, Priel E, Yassur Y, Weinberger D. Comparison of fluorescein angiography and indocyanine green angiography for imaging of choroidal neovascularization in hemorrhagic age-related macular degeneration. Am J Ophthalmol. 2000;129(4):495-500.

Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials. Macular Photocoagulation Study Group. Arch Ophthalmol. 1993;111(9):1200-1209.

Mandava N, Guyer DR, Yannuzzi LA, Nichol J, Orlock D. Principles of fluorescein angiography. In: Yannuzzi LA, Guyer DR, Chang S, Shields J, Green WR, eds. Retina- Vitreous-Macula. A Comprehensive Text. Philadelphia: W.B. Saunders;1999:29-38.

Mayfield J. Who cares about the quality of diabetes care? Almost everyone! Clin Diabetes. 1998;16(4):161-167.

Obana A, Gohto Y, Matsumoto M, Miki T, Nishiguti K. Indocyanine green angiographic features prognostic of visual outcome in the natural course of patients with age related macular degeneration. Br J Ophthalmol. 1999;83(4):429-437.

Pece A, Sannace C, Menchini U, et al. Fluorescein angiography and indocyanine green angiography for identifying occult choroidal neovascularization in age-related macular degeneration. Eur J Ophthalmol. 2005;15(6):759-763.

Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of age-related macular degeneration. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990;108(6):825-831.

Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989;107(3):344-352.

Recurrent choroidal neovascularization after argon laser photocoagulation for neovascular maculopathy. Macular Photocoagulation Study Group. Arch Ophthalmol. 1986;104(4):503-512.

Regillo CD, Benson WE, Maguire JI, Annesley WH. Indocyanine green angiography and occult choroidal neovascularization. Ophthalmology. 1994;101(2):280-288.

Regillo CD, Blade KA, Custis PH, O'Connell SR. Evaluating persistent and recurrent choroidal neovascularization. The role of indocyanine green angiography. Ophthalmology. 1998;105(10):1821-1826.

Reichel E, Duker JS, Puliafito CA. Indocyanine green angiography and choroidal neovascularization obscured by hemorrhage. Ophthalmology. 1995;102(12):1871-1876.

Risk factors for neovascular age-related macular degeneration. The Eye Disease Case-Control Study Group. Arch Ophthalmol. 1992;110(12):1701-1708.

Singh RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195-208.

Slakter JS, Giovannini A, Yannuzzi LA, et al. Indocyanine green angiography of multifocal choroiditis. Ophthalmology. 1997;104(11):1813-1819.

Stanga PE, Lim JI, Hamilton P. Indocyanine green angiography in chorioretinal diseases: Indications and interpretation: An evidence-based update. Ophthalmology. 2003;110(1):15-21.

Sykes SO, Bressler NM, Maguire MG, Schachat AP, Bressler SB. Detecting recurrent choroidal neovascularization: Comparison of clinical examination with and without fluorescein angiography. Arch Ophthalmol. 1994;112(12):1561-1566.

Vadalà M, Lodato G, Cillino S. Multifocal choroiditis: Indocyanine green angiographic features. Ophthalmologica. 2001;215(1):16-21.

Van Liefferinge T, Sallet G, De Laey JJ. Indocyanine green angiography in cases of inflammatory chorioretinopathy. Bull Soc Belge Ophtalmol. 1995;257:73-81.

Watzke RC, Klein ML, Hiner CJ, Chan BK, Kraemer DF. A comparison of stereoscopic fluorescein angiography with indocyanine green videoangiography in age-related macular degeneration. Ophthalmology. 2000;107(8):1601-1606.

Wolf S, Kirchhof B, Reim M. The Ocular Fundus: From Findings to Diagnosis. Stuttgart, Germany:Georg Thieme Verlag;2006.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
07/15/2021	R19	Under *CMS National Coverage Policy* headings were added and descriptions were updated for regulations. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Acronyms were inserted and defined where appropriate throughout the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD.	Provider Education/Guidance
10/24/2019	R18	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: Ophthalmic Angiography (Fluorescein and Indocyanine Green) A56774 article. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. 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
08/01/2019	R17	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) A56774 article and removed from the LCD. 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
07/05/2018	R16	Under Coverage Indications, Limitations and/or Medical Necessity – Indications added bullet in front of “Retinal hemorrhage”. Under Coverage Indications, Limitations and/or Medical Necessity – Other Comments added the verbiage Comprehensive Outpatient Rehabilitation Facilities before the acronym CORFs. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Punctuation was corrected as appropriate throughout the policy. At this time 21^stCentury 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 Public Education/Guidance
02/26/2018	R15	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	R14	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	R13	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* added ICD-10 codes H44.2A1, H44.2A2, H44.2A3, H44.2B1, H44.2B2, H44.2B3, H44.2E1, H44.2E2 and H44.2E3. This revision is due to the 2017 Annual ICD-10 Code 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.	Revisions Due To ICD-10-CM Code Changes
08/03/2017	R12	Under *CMS National Coverage Policy* corrected the titles for 42 CFR §410.74, §410.75, and §410.76. Under *ICD-10 Codes That Support Medical* *Necessity-ICD-10 Codes for Fluorescein Angiography (92235) - Group 1: Codes* deleted H34.10, M05.411, M05.412, M05.421, M05.422, M05.431, M05.432, M05.441, M05.442, M05.451, M05.452. M05.461, M05.462, M05.471, M05.472, M05.49, M05.511, M05.512, M05.521, M05.522, M05.531, M05.532, M05.541, M05.542, M05.551, M05.552, M05.561, M05.562, M05.571, M05.572, M05.59, M05.711, M05.712, M05.721, M05.722, M05.731, M05.732, M05.741, M05.742, M05.751, M05.752, M05.761, M05.762, M05.771, M05.772, M05.79, M05.811, M05.812, M05.821, M05.822, M05.831, M05.832, M05.841, M05.842, M05.851, M05.852, M05.861, M05.862, M05.871, M05.872, M05.89, M05.9, M06.011, M06.012, M06.021, M06.022, M06.031, M06.032, M06.041, M06.042, M06.051, M06.052, M06.061, M06.062, M06.071, M06.072, M06.08, M06.09, M06.211, M06.212, M06.221, M06.222, M06.231, M06.232, M06.241, M06.242, M06.251, M06.252, M06.261, M06.262, M06.271, M06.272, M06.28, M06.29, M06.311, M06.312, M06.321, M06.322, M06.331, M06.332, M06.341, M06.342, M06.351, M06.352, M06.361, M06.362, M06.371, M06.372, M06.38, M06.39, M06.811, M06.812, M06.821, M06.822, M06.831, M06.832, M06.841, M06.842, M06.851, M06.852, M06.861, M06.862, M06.871, M06.872, M06.88, and M06.89. Under *ICD-10 Codes That Support Medical Necessity-ICD-10 Codes for Indocyanine Green Angiography (92240)-Group 2: Codes* deleted H35.059 and added ICD-10 codes D31.31 and D31.32. Under *Sources of Information and Basis for Decision* corrected punctuation and spelling, and deleted the two National Guideline Clearinghouse citations as these were archived.	Provider Education/Guidance Typographical Error Reconsideration Request
05/15/2017	R11	Under *ICD-10 Codes that Support Medical Necessity Group 1: Codes* added ICD-10 codes H59.031, H59.032 and H59.033.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes Reconsideration Request
01/01/2017	R10	Under *ICD-10 Codes that Support Medical Necessity Group 2: Codes* added ICD-10 codes H34.01 and H34.02.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
01/01/2017	R9	Under *CPT/HCPCS Codes Group 1 Paragraph* added an asterisk and the verbiage “CPT Code 92242 can only be billed with a single diagnosis if that diagnosis is a covered diagnosis for both CPT Code 92235 and CPT Code 92240. If the diagnosis to be billed for CPT 92242 is only a covered diagnosis for one of the two procedures encompassed in CPT 92242, the provider also needs to include a second diagnosis code on the claim that is a covered diagnosis for the other of the two studies in order to indicate that there exists a covered diagnosis for both studies included in CPT 92242. Under *CPT/HCPCS Codes Group 1* added CPT Code 92242 and code descriptions changed for CPT Codes 92235 and 92240. This revision is due to the 2017 Annual CPT/HCPCS Update and becomes effective 01/01/17.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
11/28/2016	R8	Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes H35.3111, H35.3112, H35.3113, H35.3114, H35.3121, H35.3122, H35.3123, H35.3124, H35.3131, H35.3132, H35.3133, H35.3134, H35.3211, H35.3212, H35.3213, H35.3221, H35.3222, H35.3223, H35.3231 and H35.3232 as these codes were inadvertently omitted. This revision is due to the Annual ICD-10 Update. These codes are effective on or after October 01, 2016. Also, added ICD-10 codes H35.3233, H35.361, H35.362, H35.363, H43.11, H43.12, H43.13, H43.821, H43.822, H43.823 and Z79.899 due to a reconsideration request.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes Reconsideration Request
10/24/2016	R7	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes and Group 2: Codes* added ICD-10 codes H34.03, 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 and H34.8332. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/24/16.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
10/24/2016	R6	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, E08.3539, 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, E10.3599, 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, E78.00, E78.01, E89.820, E89.821, E89.822, and E89.823. Under *ICD-10 Codes That Support Medical Necessity: Group 1* deleted E08.329, E08.341, E09.329, E09.339, E09.341, E11.329, E11.331, E13.359, H34.831, E08.321, E08.349, E09.321, E09.331, E09.351, E10.341, E10.351, E08.339, E08.359, E09.359, E10.321, E10.339, E10.349, E10.329, E10.331, E10.359, E11.341, E11.359, E13.329, E13.331, E13.349, H34.811, E11.349, E11.351, E13.321, E13.339, E13.341, H34.812, H34.813, H34.833, E11.321, E11.339, E13.351, H34.832, H35.32, E08.331, E08.351, and E09.349. Under *ICD-10 Codes That Support Medical Necessity: Group 2* added H35.3210, H35.3211, H35.3212, H35.3213, H35.3220, H35.3221, H35.3222, H35.3223, H35.3230, H35.3231, H35.3232, and H35.3233. Under *ICD-10 Codes That Support Medical Necessity: Group 2* deleted H35.32. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2016.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
10/24/2016	R5	Comments were received from the provider community and are attached to the LCD under the *Related Local Coverage Documents.* Under *ICD-10 Codes that DO NOT Support Medical Necessity* deleted the *Group 1: Paragraph* and all *Group 1: Codes* due to comments received.	Provider Education/Guidance
08/04/2016	R4	Under *ICD-10 Codes that Support Medical Necessity Group 1: Codes* added E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E09.321, E09.329, E09.339, E09.341, E09.349, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E13.321, E13.329, E13.331, E13.339, E13.341 and E13.349. Under *ICD-10 Codes that Support Medical Necessity Group 2: Codes* added H35.053 and H35.32.	Reconsideration Request
10/01/2015	R3	This LCD is being reactivated effective 10/01/2015 due to the implementation of Change Request 9252, Transmittal 1537, One-Time Notification related to NCDs 80.2, 80.2.1, 80.3 and 80.3.1. Under *CMS National Coverage Policy* added “a” to the following: 42 CFR §410.32 and added section 80.3.1 to the following: CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1. Under *ICD-10 Codes That Support Medical Necessity- Group 1 ICD-10 Codes for Fluorescein Angiography (92235)* deleted ICD-10 codes H35.30 and H35.31 as these are non-covered codes and added ICD-10 codes B39.4 and B39.5. Under *Associated Information-Documentation Requirements* deleted “J11” from the last sentence of the last paragraph. Under *Sources of Information and Basis for Decision* deleted the author names Virgili G and Bini A from the following cited source: Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials. Macular Photocoagulation Study Group. Arch Ophthalmol. 1993;111(9):1200-1209.	Provider Education/Guidance Other
04/17/2015	R2		LCD Being Retired
10/01/2015	R1	Under CMS National Coverage Policy added citations for Pub. 100-03, Chapter 1, Part 1 Sections 80.2 and 80.2.1. Under Coverage indications, Limitations and/or Medical Necessity corrected the second sentence to read “Its visible fluorescence leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular disorders and monitoring treatment of conditions amenable to laser photocoagulation”. Under Sources of Information and Basis for Decision corrected url links to become hyperlinks where applicable, made grammatical and punctuation corrections to several citations, and added authors Virgili G and Bini A to citation for Laser photocoagulation of subfoveal neovascular lesions.	Provider Education/Guidance Other (Annual Validation)

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Ophthalmic Angiography (Fluorescein and Indocyanine Green)

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