Anthem Blue Cross Connecticut CG-MED-85 Posterior Segment Optical Coherence Tomography Form

Subject:

Description

This document addresses optical coherence tomography of the posterior segment of the eye. Posterior segment ocular structures include the choroid, optic nerve, macula, retina, and vitreous.

Clinical Indications

Medically Necessary:

Initial optical coherence tomography of the posterior segment of the eye is considered medically necessary for any of the following:

1. To establish a diagnosis of a condition affecting the optic nerve or retina (including, but not limited to glaucoma, optic neuropathy, macular degeneration, diabetic retinopathy, macular edema, atrophy associated with degenerative retinal diseases), when a clinical diagnosis is uncertain; or
2. To establish a baseline prior to treatment of a condition affecting the optic nerve or retina.

Repeat optical coherence tomography of the posterior segment of the eye is considered medically necessary to monitor a condition affecting the optic nerve or retina when there is documentation that changes detected on imaging (based on the anticipated clinical progression of the underlying disease) are likely to impact management; for example:

1. To monitor for disease progression in individuals with glaucoma; or
2. To manage retinal conditions undergoing active treatment (such as wet age-related macular degeneration, choroidal neovascularization, macular edema, diabetic retinopathy [proliferative and nonproliferative], branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema) (that is: used for therapeutic decision making based on the individual’s treatment protocol and clinical response as documented in the medical record); or
3. To monitor for development of retinopathy for individuals receiving long-term use of chloroquine or hydroxychloroquine.

Not Medically Necessary:

Initial and repeat optical coherence tomography of the posterior segment of the eye is considered not medically necessary when the above criteria are not met and for all other indications including, but not limited to multiple sclerosis and amyloidosis.