L29197-LCD

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Local Coverage Determination (LCD) for Indocyanine-Green Angiography (L29197)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29197

LCD Title

Indocyanine-Green Angiography

Contractor's Determination Number 92240

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Indocyanine – green (ICG) angiography is an infrared-based, dye imaging technique that is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age - related macular degeneration). Indocyanine - green dye is injected intravenously into the patient to highlight the vessels in the retina and those of a deeper tissue layer called the choroid. The green dye fluoresces with invisible infrared light and requires a special camera sensitive to these light rays. Photographs are then taken of the retina at intervals as increasing intensity of retinal and choroidal circulation is displayed.

Medicare will consider indocyanine - green (ICG) angiography to be medically necessary as an adjunct to fluorescein angiography (FA) in the evaluation of the following conditions:

• Serous detachment of retinal pigment epithelium

• Hemorrhagic detachment of retinal pigment epithelium

• Retinal hemorrhage

• Presence of subretinal hemorrhage or hemorrhagic retinal pigment epithelium (RPE). A fluorescein angiography need not be previously done if patient is allergic to fluorescein

• Central serous retinopathy

• Focal and disseminated choroiditis

In the absence of pre-existing chronic disease, clinical signs or symptoms of disease, an ICG angiography is considered screening and is not a benefit of the Medicare program. Also, a bilateral study is not automatically appropriate, or covered, in every case. Therefore, evidence of medical necessity must be documented in the medical record for each eye.

Contraindications to ICG angiography include prior ananaphylactic reaction to ICG dye or contrast agents that contain iodide, liver disease, uremia, and pregnancy.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

92240 INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT

ICD-9 Codes that Support Medical Necessity

362.41 CENTRAL SEROUS RETINOPATHY

362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM

362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.81 RETINAL HEMORRHAGE

363.00 - 363.08 opens in new window

363.10 - 363.15 opens in new window

FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 CHORIORETINITIS UNSPECIFIED

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must indicate the medical necessity of the indocyanine - green angiography. Office records/progress notes must document the complaint, symptomatology, or reason necessitating the test and must include the examination results/findings.

Appendices

Utilization Guidelines Following the performance of indocyanine - green angiography, fluorescein angiography can be considered medically necessary and reimbursable when performed on the same eye, within a one month timeframe of the ICG. Both procedures (i.e., ICG, FA) may be allowed on the same day when additional diagnostic information is medically necessary.

Generally, only one ICG is medically necessary prior to and following a course of treatment. Services in excess of this standard of care must be reflected in the patients’ medical records to support the medical necessity of more frequent testing.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Charters, L. (2001). New diagnostic tools can help to identify CSC disorder. Ophthalmology Times, 26(6), 58-60. Retrieved August 18, 2004, from Proquest.umi.com database (70064123).

Chopdar, A., Chakravarthy, U., Verma, D. (2003). Age related macular degeneration. British Medical Journal, 326(7387), 485-489. Retrieved August 18, 2004, Proquest.umi.com database (320589311).

Ciardella, A., Borodoker, N., Costa, D., Huang, S., Cunningham, E., & Slakter, J. (2002). Imaging the posterior segment in uveitis. Ophthalmology Clinics of North America, 15(3). Retrieved July 20, 2004, from mdconsult.com database (39229780).

Glenn, C. (2001). Revisiting feeder vessel treatment. Review of Ophthamology, 8(8), 41-45. Nissen, D. (Ed.). (2004). Mosby’s Drug Consult. St. Louis, MO: Mosby.

Yanoff. (2004). Ophthalmology (2nd ed.). St. Louis, MO: Mosby.

Zarfati, D., Harris, A., Garzozi, H., Zacish, M., Kagemann, L., Jonescu-Cuypers, C., Martin, B. (2000). A review of ocular blood flow measurement techniques. Neuro-Ophthalmology, 24(3), 401-410.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29197) replaces LCD L5663 as the policy in notice. This document (L29197) is effective on 02/02/2009.

Reason for Change