L29276-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Scanning Computerized Ophthalmic

Diagnostic Imaging (SCODI) (L29276)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29276

LCD Title

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Contractor's Determination Number 92132

Primary Geographic Jurisdiction 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

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: National Coverage Determinations Manual, sections 80.6, 80.9, 140.5, and 220.1

National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology

Indications and Limitations of Coverage and/or Medical Necessity

Many forms of scanning computerized ophthalmic diagnostic imaging (SCODI)tests currently exist (e.g., confocal laser scanning ophthalmoscopy (topography), scanning laser polarimetry, optical coherence tomography (OCT), and retinal thickness analysis). Although these techniques are different, their objective is the same.

Confocal scanning laser ophthalmoscopy (topography) uses multiple tomographic images to make quantitative topographic measurements of either the optic nerve head or posterior retinal structures to detect glaucomatous damage to the nerve fiber layer of the retina or non-glaucomatous retinal changes in the microstructure of the posterior retina (e.g. macular edema, atrophy associated with degenerative retinal diseases).

Scanning laser polarimetry measures change in the linear polarization of light (retardation). It uses a polarimeter, an optical device to measure linear polarization change and a scanning laser ophthalmoscope together to

measure the thickness of the nerve fiber layer of the retina.

Optical coherence tomography is a non-invasive, non-contact imaging technique. It produces high-resolution, longitudinal, cross-sectional tomographs of ocular structures to detect evidence of glaucomatous damage or subsurface retinal defects.

Retinal thickness analysis is a computerized slitlamp biomicroscope that is intended to provide manual and computerized tomography of the retina in vivo to determine the thickness and the inner structure of the retina. It is indicated for assessing the area and location of retinal thickness abnormalities, such as thickening due to macular edema and atrophy associated with degenerative diseases, and for visualizing other retinal pathologies.

Indications of Coverage for Posterior Segment SCODI

Posterior segment SCODI allows for early detection of glaucomatous damage to the nerve fiber layer or optic nerve of the eye. It is the goal of these diagnostic imaging tests to discriminate among patients with normal intraocular pressures (IOP) who have glaucoma, patients with elevated IOP who have glaucoma, and patients with elevated IOP who do not have glaucoma. These tests can also provide precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of follow-up exams than visual field and/or disc photos. This can allow earlier and more efficient efforts of treatment toward the disease process.

Retinal disorders are the most common causes of severe and permanent vision loss. SCODI is also used for the evaluation and treatment of patients with retinal disease, especially certain macular abnormalities. It details the microscopic anatomy of the retina and the vitreo-retinal interface.

FCSO Medicare will consider posterior segment SCODI medically reasonable and necessary under the following circumstances:

1. The patient presents with “mild” glaucomatous damage or “suspect glaucoma” as demonstrated by any of the following:

- Intraocular pressure ³ 22mmHg as measured by applanation;

- Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio > 0.4;

- Diffuse or focal narrowing or notching of disc rim, especially at inferior or superior poles;

- Diffuse or localized abnormalities of the retinal nerve fiber layer, especially at the inferior or superior poles;

- Nerve fiber layer disc hemorrhage;

- Asymmetrical appearance of the optic disc or rim between fellow eyes that suggests loss of neural tissue;

- Nasal step peripheral to 20 degrees or small paracentral or arcuate scotoma; or

- Mild constriction of visual field isopters.

Because of the slow disease progression of patients with “suspect glaucoma” or those with “mild” glaucomatous damage, the use of scanning computerized ophthalmic diagnostic imaging at a frequency of > 1/year is not expected.

2. The patient presents with “moderate” glaucomatous damage as demonstrated by any of the following:

- Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio > 0.5 but < 0.8;

- Definite focal notch with thinning of the neural rim; or

- Definite glaucomatous visual field defect (e.g., arcuate defect, nasal step, paracentral scotoma, or general depression).

Patients with “moderate damage” may be followed with scanning computerized ophthalmic diagnostic imaging and/or visual fields. One or two tests of either per year may be appropriate. If both scanning computerized ophthalmic diagnostic imaging and visual field tests are used, only one of each test would be considered medically necessary, as these tests provide duplicative information.

Scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary for patients with “advanced” glaucomatous damage. Instead, visual field testing should be performed. (Late in the course of glaucoma, when the nerve fiber layer has been extensively damaged, visual fields are more likely to detect small changes than scanning computerized ophthalmic diagnostic imaging).

The patient with “advanced” glaucomatous damage would demonstrate any of the following:

- Diffuse enlargement of optic nerve cup, with cup to disc ratio > 0.8;

- Wipe-out of all or a portion of the neural retinal rim;

- Severe generalized constriction of isopters (i.e., Goldmann I4e ,< 10 degrees of fixation);

- Absolute visual field defects to within 10 degrees of fixation;

- Severe generalized reduction of retinal sensitivity; or

- Loss of central visual acuity, with temporal island remaining.

In addition, scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary when performed to provide additional confirmatory information regarding a diagnosis which has already been determined.

Limitations of Coverage for Posterior Segment SCODI

Performing Fundus Photography and SCODI on the Same Day on the Same Eye

Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133 or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250 (National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology).

The physician is not precluded from performing fundus photography and posterior segment SCODI on the same eye on the same day under appropriate circumstances (i.e., when each service is necessary to evaluate and treat the patient.

FCSO Medicare will consider fundus photography and posterior segment SCODI medically reasonable and necessary when performed on the same eye on the same day as outlined below.

Fundus photography and Posterior Segment SCODI are frequently used together for the following diagnoses

115.02

190.6

224.6

228.03

360.21

360.30-360.34

361.00-361.07

361.10-361.19

361.2

361.30-361.33

361.81

362.01

362.02

362.03

362.04

362.05

362.06

362.07

362.10-362.18

362.29

362.31

362.32

362.35

362.36

362.37

362.40-362.43

362.50-362.57

362.70-362.77

362.81

362.82

362.83

362.85

363.00-363.08

363.10-363.15

363.20-363.22

363.30-363.35

363.40-363.43

363.54

363.63

363.70-363.72

743.58

Indications of Coverage for Anterior Segment SCODI

FCSO Medicare will consider anterior segment SCODI medically reasonable and necessary for evaluation of specified forms of glaucoma and disorders of the cornea, iris and ciliary body.

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

92132 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

92133 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE

92134 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA

ICD-9 Codes that Support Medical Necessity

ICD-9-CM codes applicable for CPT codes 92133 and 92134 (Do not report 92133 and 92134 at the same patient encounter)

115.02 HISTOPLASMA CAPSULATUM RETINITIS

190.6 MALIGNANT NEOPLASM OF CHOROID

191.1 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.2 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.3 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.4 MALIGNANT NEOPLASM OF PARIETAL LOBE

224.6 BENIGN NEOPLASM OF CHOROID

228.03 HEMANGIOMA OF RETINA

360.11 SYMPATHETIC UVEITIS

360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA

360.30 - 360.34 HYPOTONY OF EYE UNSPECIFIED - FLAT ANTERIOR CHAMBER OF EYE

361.00 - 361.07 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL

361.10 - 361.19 RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS

361.2 SEROUS RETINAL DETACH 361.30 - 361.33 RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH

361.81 TRACTION DETACH OF RETINA

362.1 BACKGROUND DIABETIC RETINOPATHY

362.2 PROLIFERATIVE DIABETIC RETINOPATHY

362.3 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS

362.4 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY

362.5 MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.6 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.7 * DIABETIC MACULAR EDEMA

362.10 - 362.18 opens in

new window BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS

362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.31 CENTRAL RETINAL ARTERY OCCLUSION

362.32 RETINAL ARTERIAL BRANCH OCCLUSION

362.35 CENTRAL RETINAL VEIN OCCLUSION

362.36 VENOUS TRIBUTARY (BRANCH) OCCLUSION OF RETINA

362.37 VENOUS ENGORGEMENT OF RETINA

362.40 - 362.43 RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.50 - 362.57 MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA

362.70 - 362.77 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE

362.81 RETINAL HEMORRHAGE

362.82 RETINAL EXUDATES AND DEPOSITS

362.83 RETINAL EDEMA

362.85 RETINAL NERVE FIBER BUNDLE DEFECTS

363.00 - 363.08 FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

363.10 - 363.15 DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 - 363.22 CHORIORETINITIS UNSPECIFIED - HARADA'S DISEASE

363.30 - 363.35 CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA

363.40 - 363.43 CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID

363.54 CENTRAL CHOROIDAL ATROPHY TOTAL

363.63 CHOROIDAL RUPTURE

363.70 - 363.72 CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH

364.22 GLAUCOMATOCYCLITIC CRISES

364.53 PIGMENTARY IRIS DEGENERATION

365.00 - 365.06 PREGLAUCOMA UNSPECIFIED - PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

365.10 - 365.15 OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.20 - 365.24 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE- CLOSURE GLAUCOMA

365.31 - 365.32 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE - CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.41 - 365.44 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 - 365.59 PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 - 365.65 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA

365.81 - 365.89 HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA

368.40 VISUAL FIELD DEFECT UNSPECIFIED

368.41 SCOTOMA INVOLVING CENTRAL AREA

368.42 SCOTOMA OF BLIND SPOT AREA

368.43 SECTOR OR ARCUATE VISUAL FIELD DEFECTS

368.44 OTHER LOCALIZED VISUAL FIELD DEFECT

368.45 GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION

376.00 - 376.9 ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - UNSPECIFIED DISORDER OF ORBIT

377.00 - 377.04 PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME

377.10 - 377.16 OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY

377.21 - 377.24 DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.31 OPTIC PAPILLITIS

377.39 OTHER OPTIC NEURITIS

377.41 - 377.49 ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE

379.11 - 379.19 SCLERAL ECTASIA - OTHER SCLERAL DISORDERS

379.21 - 379.29 VITREOUS DEGENERATION - OTHER DISORDERS OF VITREOUS

743.20 - 743.22 BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES

743.57 SPECIFIED CONGENITAL ANOMALIES OF OPTIC DISC

743.58 VASCULAR ANOMALIES CONGENITAL

743.59 OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT

921.3 CONTUSION OF EYEBALL

* ICD-9-CM code 362.07 (Diabetic macular edema) requires a dual diagnosis. 362.07 must be used with an ICD- 9-CM code for diabetic retinopathy (ICD-9-CM codes 362.01-362.06).

ICD-9-CM codes applicable for CPT code 92132:

190.0

MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.4 MALIGNANT NEOPLASM OF CORNEA

224.0 BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

224.4 BENIGN NEOPLASM OF CORNEA

364.51 - 364.59 ESSENTIAL OR PROGRESSIVE IRIS ATROPHY - OTHER IRIS ATROPHY

364.60 - 364.64 IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY - EXUDATIVE CYST OF PARS

364.70 - 364.77 PLANA ADHESIONS OF IRIS UNSPECIFIED - RECESSION OF CHAMBER ANGLE OF EYE

364.81 - 364.89 FLOPPY IRIS SYNDROME - OTHER DISORDERS OF IRIS AND CILIARY BODY

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.06 PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

365.20 - 365.24 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF

ANGLE-CLOSURE GLAUCOMA

365.41 - 365.44 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 - 365.59 PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS

DISORDERS

365.60 - 365.65 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA

365.81 - 365.89 ASSOCIATED WITH OCULAR TRAUMA

HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA

370.4 HYPOPYON ULCER

370.5 MYCOTIC CORNEAL ULCER

370.6 PERFORATED CORNEAL ULCER

371.03 CENTRAL OPACITY OF CORNEA

371.71 CORNEAL ECTASIA

371.72 DESCEMETOCELE

371.73 CORNEAL STAPHYLOMA

379.31 APHAKIA

379.32 SUBLUXATION OF LENS

379.33 ANTERIOR DISLOCATION OF LENS

379.39 OTHER DISORDERS OF LENS

996.51 MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT

996.53 MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS

996.69 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

• Medical record documentation (e.g., office/progress notes) maintained by the performing physician must indicate the medical necessity of the scanning computerized ophthalmic diagnostic imaging

and be available to Medicare upon request

•A copy of the test results, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams is required.

•Medical record documentation must clearly indicate rationale which supports the medical necessity for performing the fundus photography and posterior segment SCODI on the same day on the same eye. Documentation should also reflect how the test results were used in the patient’s plan of care.

• It would not be considered medically reasonable and necessary to perform fundus photography and posterior segment SCODI on the same day on the same eye to provide additional confirmatory information for a diagnosis or treatment which has already been determined.

Appendices

Utilization Guidelines 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

Antcliff, R., Stanford, M., Chauhan, D., Graham, E., Spalton, D., Shilling, J, Ffytche, T. Marshall, J. (2000). Comparison between optical coherence tomography and fundus fluorescein angiography for the detection of cystoid macular edema in patients with uveitis. Ophthalmology, 107, 593-599.

Antcliff, R., Spalton, D., Stanford, M., Graham, E., Ffytche, T., Marshall, J. (2001). Intravitreal triamcinolone for uveitic cystoid macular edema: An optical coherence tomography study. Ophthalmology, 108(4), 765-772.

Azzolini, C., Patelli, F., Codenotti, M., Pierro, L., Brancato, R. (1999). Optical coherence tomography in idiopathic epiretinal macular membrane surgery. Eur J Ophthalmol, 9, 206-211.

Bakri, S., Singh, A., Lowder, C., Chalita, M., Li, Y., Izatt, J., Rollins, A., & Huang, D. (2007). Imaging of iris lesions with high-speed optical coherence tomography. Ophthalmic Surg Lasers Imaging, 38, 27-34.

Blumenthal, E., Williams, J., Weinreb, R., Girkin, C., Berr, C., Zangwill, L. (2000). Reproducibility of nerve fiber layer thickness measurements by use of optical coherence tomography. Ophthalmology, 107(12), 2278-2282.

Fujii, G., De Juan, E., Bressler, N. (2001). Vitrectomy surgery for impending macular hole based on optical coherence tomography.Retina, 21(4), 389-392.

Gallemore, R., Jumper, M., McCuen, B., Jaffe, G., Postel, E., Toth, C. (2000). Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina, 20(2), 115-120.

Garcia, J., Cruz, J., Rosen, R., & Buxton, D. (2008). Imaging implanted keratoprostheses with anterior-segment optical coherence tomography and ultrasound biomicroscopy. Cornea, 27, 180-188.

Garcia, J., Garcia, P., Buxton, D., Panarelli, A., & Rosen, R. (2007). Imaging through opaque corneas using anterior segment optical coherence tomography. Ophthalmic Surg Lasers Imaging, 38(4), 314-318.

Giovannini, A., Amato, G., Mariotti, C., Scassellati-Sforzolini, B. (2000). Optical coherence tomography in the assessment of retinal pigment epithelial tear. Retina, 20, 37-40.

Goebel, W., Kretzchmar-Gross, T. (2002). Retinal thickness in diabetic retinopathy-A study using optical coherence tomography (OCT). Retina, 22, 759-767.

Haouchine, B., Massin, P., Gaudric, A. (2001). Foveal pseudocyst as the first step in macular hole formation-A prospective study by optical coherence tomography. Ophthalmology, 108, 15-22.

Ito, Y., Terasaki, H., Mori, M., Kojima, T., Suzuki, T., Miyake, Y. (2000). Three-dimensinal optical coherence tomography of vitreomacular traction syndrome before and after vitrectomy. Retina, 20(4), 403-405.

Kim, H., Budenz, D., Lee, P., Feuer, W., & Barton, K. (2008). Comparison of central corneal thickness using anterior segment optical coherence tomography vs ultrasound pachymetry. Am J Ophthalmol, 145(2). Retrieved June 24, 2008 from MD Consult database (98160416-3).

Lai, M., Tang, M., Andrade, E., Li, Y., Khurana, R., Song, J., & Huang, D. (2006). Optical coherence tomography to assess intrastromal corneal ring segment depth in keratoconic eyes. J Cataract Refract Surg, 32, 1860-1865.

Lee, R., & Ahmed, I. (2006). Anterior segment optical coherence tomography: Non-contact high resolution imaging of the anterior chamber. Techniques in Ophthalmology, 4(3), 120-127.

Memarzadeh, F., Li, Y., Chopra, V., Varma, R., Francis, B., & Huang, D. (2007). Anterior segment optical coherence tomography for imaging the anterior chamber after laser peripheral iridotomy. Am J Ophthalmol, 143(5), 877-879.

Memarzadeh, F., Li, Y., Francis, B., Smith, R., Gutmark, J., & Huang, D. (2007). Optical coherence tomography of the anterior segment in secondary glaucoma with corneal opacity after penetrating keratoplasty. Br J Ophthalmol, 91, 189-192.

Memarzadeh, F., Tang, M., Li, Y., Chopra, V., Francis, B., & Huang, D. (2007). Optical coherence tomography assessment of angle anatomy changes after cataract surgery. Am J Ophthalmol, 144(3), 464-465.

Pons, M., Ishikawa, H., Gurses-Ozden, R., Liebmann, J., Dou, H., Ritch, R. (2000). Assessment of retinal nerve fiber layer internal reflectivity in eyes with and without glaucoma using optical coherence tomography. Arch Ophthalmol, 118, 1044-1047.

Radhakrishnan, S., Goldsmith, J., Huang, D., Westphal, V., Dueker, D., Rollins, A., Izatt, J., & Smith, S. (2005). Comparison of optical coherence tomography and ultrasound biomicroscopy for detection of narrow anterior chamber angles. Arch Ophthalmol, 123, 1053-1059.

Ripandelli, G., Coppe, A., Bonini, S., Giannini, R., Curci, S., Costi, E., Stirpe, M. (1999). Morphological evaluation of full-thickness idiopathic macular holes by optical coherence tomography. Eur J Ophthalmol, 9, 212-216.

Shields, M.B. (Ed.). (1998). Textbook of Glaucoma (4th ed.). Baltimore: Williams and Wilkins. Smith, S. (July 2007). Anterior segment OCT and angle closure. Review of Ophthalmology, 80-82.

Tadayoni, R., Massin, P., Haouchine, B., Cohen, D., Erginay, A., Gaudric, A. (2001). Spontaneous resolution of small stage 3 and 4 full-thickness macular holes viewed by optical coherence tomography. Retina, 21(2), 186- 189.

Tanner, V., Williamson, T. (2000). Watzke-Allen slit beam test in macular holes confirmed by optical coherence tomography. Arch Ophthalmol, 118, 1059-1063.

Ting, T., Oh, M., Cox. T., Meyer, C., Toth, C. (2002). Decreased visual acuity associated with cystoid macular edema in neovascular age-related macular degeneration. Arch Ophthalmol, 120, 731-737.

Uchino, E., Uemura, A, Ohba, N. (2001). Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol, 119, 1475-1479.

Wolffsohn, J., & Davies, L. (2007). Advances in ocular imaging. Expert Rev Ophthalmol, 2(5), 755-767. Yanoff, M. (Ed.). (1998). Ophthalmic Diagnosis and Treatment. Philadelphia: Current Medicine, Inc.

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.

Florida Contractor Advisory Committee Meeting held on October 16, 2010.

Puerto Rico/U.S. Virgin Islands Contractor Advisory Meeting held on October 21, 2010.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/30/2010

Revision History Number 4

Revision History Explanation Revision Number:4 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Diagnosis range 365.00-365.04 (borderline glaucoma [glaucoma suspect]) revised to 365.00-365.06 to add new diagnosis codes 365.05 and 365.06 for procedure codes 92133 and 92134. Added diagnosis code 365.06 for procedure code 92132. The effective date of this revision is based on date of service.

Revision Number:3

Start Date of Comment Period:10/21/2010 Start Date of Notice Period:12/30/2010 Revised Effective Date: 02/13/2011

LCR B2010-083

December 2010 Update

Explanation of Revision: The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD has been revised to add a new ‘Limitations’ section under the ‘Indications of Coverage for Posterior Segment

SCODI’ section to add language regarding performing fundus photography and scanning computerized ophthalmic diagnostic imaging, posterior segment (SCODI) on the same day on the same eye. A table has also been added

to outline diagnoses which will be considered medically reasonable and necessary for fundus photography and posterior segment SCODI (CPT code 92133 or 92134) when performed on the same eye on the same day. The effective date of this revision is based on date of service.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2011 Revised Effective Date: 01/01/2011

LCR B2010-013

December 2010 Update

Explanation of Revision: Annual 2011 HCPCS Update. CPT code 92135 was deleted and replaced with CPT codes 92133 and 92134. CPT code 0187T was deleted and replaced with CPT code 92132. The ‘Documentation Requirements’ section of the LCD has also been updated. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:02/20/2009 Start Date of Notice Period:05/01/2009 Revised Effective Date: 06/30/2009

LCR B2009-060

April 2009 Update

Explanation of Revision: ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of LCD revised to include language pertaining to anterior segment SCODI, ‘CPT/HCPCS Codes’ section revised to include CPT code 0187T. Also, a new section, ‘ICD-9-CM codes applicable for CPT code 0187T’, was added to the LCD, the ‘Documentation Requirements’ section has been revised to include language regarding CPT code 0187T and the

‘Sources of Information and Basis for Decision’ section of LCD has been updated accordingly. The effective date of this revision is based on date of service.

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 (L29276) replaces LCD L6435 as the policy in notice. This document (L29276) is effective on 02/02/2009.

11/21/2010 - The following CPT/HCPCS codes were deleted: 0187T was deleted from Group 1

92135 was deleted from Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change