CMS Visual Field Examination Form

Summary Of Evidence

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Analysis of Evidence

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History/Background and/or General Information

The visual field is the area within which objects may be seen when the eye is fixed. To standardize testing, several automated and computerized perimeters are available. However, manual perimeters are also utilized.

Covered Indications

Visual field examinations will be considered medically reasonable and necessary under any of the following conditions:

• The patient has inflammation or disorders of the eyelids potentially affecting the visual field.
• The patient has a documented diagnosis of glaucoma.

Please note: stabilization or progression of glaucoma can be monitored only by a visual field examination, and the frequency of such examinations is dependent on the variability of intraocular pressure measurements (e.g., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve.

• The patient is a glaucoma suspect as evidenced by an increase in intraocular pressure, asymmetric intraocular measurements of greater than 2-3 mm Hg between the two eyes, or has optic nerves suspicious for glaucoma which may be manifested as asymmetrical cupping, disc hemorrhage, or an absent or thinned temporal rim.
• The patient has a documented disorder of the optic nerve, the neurologic visual pathway, or retina.

Please note: patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field is not indicated.

• The patient has had a recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.
• The patient has a recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia, or giant cell arteritis.
• The patient is having an initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital ptosis.
• The patient has inflammation or disorders of the orbit, potentially affecting the visual field.
• The patient has sustained a significant eye injury.
• The patient has an unexplained visual loss which may be described as “trouble seeing” or “vision going in and out”.
• The patient has a pale or swollen optic nerve documented by a visual exam of recent origin.
• The patient is having some new functional limitations which may be due to visual field loss (e.g., reports by family that patient is running into things).
• The patient is being evaluated initially for macular degeneration or has experienced central vision loss resulting in vision measured at or below 20/70.

Please note: repeated examinations for a diagnosis of macular degeneration or an experienced central vision loss are not necessary unless changes in vision are documented or to evaluate the results of a surgical intervention.

• The patient is receiving or has completed treatment of a high-risk medication that may cause visual side effects (e.g., a patient on plaquenil may develop retinopathy).

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.