CMS Visual Fields Testing Form

Summary Of Evidence

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Analysis of Evidence

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Abstract:

Visual field testing detects defects in the field of vision, testing the function of the retina, optic nerve and optic pathways. Formal visual field tests are generally performed using automated perimetry, i.e., measurement of the ability to see points of light at varying locations on a curved surface.

Indications:

Visual field examinations are considered medically necessary for the conditions listed below:

1. The patient has a disorder of the eyelid(s) potentially affecting the visual field(s).
2. The patient has a visual field defect detected on gross visual field testing (e.g., confrontational testing).
3. The patient has a documented diagnosis of glaucoma.
   It should be noted that the progression of, and effects of treatment on glaucoma can be monitored only through periodic visual field testing. The frequency of such examinations is dependent on changes in intraocular pressure (IOP), retinal damage and changes at the optic disc.
4. The patient is suspected of having glaucoma; signs include increased intraocular pressure, asymmetric IOP measurements, notching or thinning of the neuroretinal rim, splinter hemorrhages and asymmetric appearance of the discs.
5. The patient has a documented disorder of the optic nerve, the retina or the neurologic visual pathway.
6. The patient has a recent intracranial hemorrhage, an intracranial mass or a recent increased intracranial pressure measurement (with or without visual symptoms).
7. The patient has a recent occlusion / stenosis of cerebral or precerebral arteries.
8. The patient has a history of a cerebral aneurysm, pituitary or occipital tumor potentially affecting the visual fields.
9. The patient is being evaluated for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.
10. The patient has a disorder of the orbit potentially affecting the visual field.
11. The patient has sustained a significant eye injury.
12. The patient has unexplained visual loss.
13. The patient has a pale or swollen optic nerve on a recent examination.
14. The patient is having new functional limitations which may be due to visual field loss (e.g., reports by family of patient bumping into objects). (change to e.g.,)
15. The patient is taking a medication with a high risk of affecting the visual system (e.g., Plaquenil).
16. The patient is being evaluated for macular degeneration, or has experienced central vision loss (< 20/70). (Repeated examinations for diagnosis of macular degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to evaluate the results of a surgical intervention).

Limitations:

Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological service and should not be reported separately.

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. 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 covered 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 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 Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)