HumanaCommercial Clinical Policy

Humana Scanning Computerized Ophthalmic Diagnostic Imaging Form


Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Notes: Coverage for SCODI posterior segment imaging is subject to specific conditions. It is not covered for any indications not listed, including monitoring or screening unrelated to the covered conditions, or when used as a biomarker for neurodegeneration. Anterior segment imaging is not covered for any indication. Always refer to the patient's individual health plan contract for the specific terms and conditions of coverage.

Indications

(286665) Is the SCODI procedure intended for the evaluation of the posterior segment (choroid, optic nerve, macula, retina, and vitreous)? 
(286666) Is the SCODI procedure being performed using one of the following techniques: Optical Coherence Tomography (OCT), scanning laser ophthalmoscopy (confocal laser scanning ophthalmoscopy), or scanning laser polarimetry (confocal scanning laser polarimetry)? 
(286667) Does the patient have a diagnosis of epiretinal membrane, glaucoma, age-related or myopic macular degeneration, or macular edema? 

Contraindications

(286668) Is SCODI being used for the initial (baseline) screening or monitoring for any medication not listed in the coverage indications? 
(286669) Is SCODI being used as a biomarker for neurodegeneration related to a medical condition such as multiple sclerosis or optic neuritis? 
YesNoN/A
YesNoN/A

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Effective Date

09/28/2023

Last Reviewed

NA

Original Document

  Reference



Description

Scanning computerized ophthalmic diagnostic imaging (SCODI) may be used as a diagnostic measure for eye conditions and includes the following technologies:

  • Optical coherence tomography (OCT) is a noninvasive, transpupillary, retinal imaging technology, that measures the echo time delay and intensity of back-reflected near-infrared light to produce high-resolution cross-sectional images. It is suggested for diagnostic use as an alternative to standard excisional biopsy and to guide interventional procedures. OCT images may be acquired using time domain, spectral domain or swept source technology.

For information regarding remote OCT, please refer to Code Compendium (Ophthalmology) Medical Coverage Policy.

Scanning Computerized Ophthalmic Diagnostic Imaging

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023

Policy Number: HUM-0510-013

Page: 2 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Scanning laser ophthalmoscopy, is a method of examining the eye using confocal laser scanning microscopy (stereoscopic videographic digitized imaging) to make quantitative topographic measurements of the optic nerve head and surrounding retina. This may be done with either reflection or fluorescence. Targeted tissues can be viewed in three-dimensional (3D) high-resolution planes running parallel to the line of sight.

Scanning laser polarimetry measures change in the linear polarization (retardation) of light. It uses both a scanning laser ophthalmoscope and a polarimeter (an optical device to measure linear polarization change) to measure the thickness of the nerve fiber layer of the retina. The confocal scanning laser polarimeter is essentially a confocal scanning laser ophthalmoscope with an additional polarization modulator, a cornea polarization compensator and a polarization detection unit.

Coverage Determination

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of conditions addressed in this policy.

Posterior Segment Imaging

Humana members may be eligible under the Plan for SCODI of the posterior segment, (choroid, optic nerve, macula, retina and vitreous), using the following techniques:

  • OCT;
  • Scanning laser ophthalmoscopy (confocal laser scanning ophthalmoscopy); OR
  • Scanning laser polarimetry (confocal scanning laser polarimetry); AND

for the following indications:

  • Epiretinal membrane; OR
  • Glaucoma; OR
  • Macular degeneration (age-related or myopic); OR
  • Macular edema; OR
Scanning Computerized Ophthalmic Diagnostic Imaging
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023

Policy Number: HUM-0510-013

Page: 3 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Macular hole; OR
  • Posterior vitreous detachment; OR
  • Retinal detachment; OR
  • Retinal vascular occlusion; OR
  • Retinopathy (diabetic or radiation); OR
  • Vitreomacular traction

Additionally, OCT imaging may be used for the following indications:

  • Initial (baseline) examination prior to or within the first year of beginning treatment with chloroquine or hydroxychloroquine; OR
  • Yearly examination after chloroquine or hydroxychloroquine use for five years or more; OR
  • Initial (baseline) examination prior to or within the first 6 months of beginning treatment with fingolimod or pentosan; OR
  • Yearly examination during treatment with fingolimod or pentosan if ophthalmological examination establishes posterior segment pathology that warrants further evaluation; OR
  • Vision changes during treatment with oncolytic medication if ophthalmological examination establishes posterior segment pathology that warrants further evaluation
Anterior Segment Imaging

Humana members may be eligible under the Plan for OCT of the anterior segment (ciliary body, cornea, iris and lens) ONLY for the evaluation of narrow angle, suspected narrow angle or mixed mechanism glaucoma when the following criteria are met:

  • Individual unable to tolerate gonioscopy due to cognitive or physical limitations; OR
  • Corneal edema or corneal opacity preclude gonioscopic visualization
Scanning Computerized Ophthalmic Diagnostic Imaging
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023

Policy Number: HUM-0510-013

Page: 4 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Posterior Segment Imaging

Humana members may NOT be eligible under the Plan for OCT for any indications other than those listed above including, but may not be limited to, the following:

  • Initial (baseline) screening or monitoring for any medication other than those listed above; OR
  • Biomarker for neurodegeneration related to a medical condition (eg, multiple sclerosis, optic neuritis)

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for SCODI of the posterior segment (choroid, optic nerve, macula, retina and vitreous), using the above techniques, for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Anterior Segment Imaging

Humana members may NOT be eligible under the Plan for anterior segment (ciliary body, cornea, iris and lens) OCT for any indication other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for anterior segment (ciliary body, cornea, iris and lens) imaging for any indication, using the following techniques:

  • Scanning laser ophthalmoscopy (confocal laser scanning ophthalmoscopy); OR
  • Scanning laser polarimetry (confocal scanning laser polarimetry)
Scanning Computerized Ophthalmic Diagnostic Imaging
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023

Policy Number: HUM-0510-013

Page: 5 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for anterior segment (ciliary body, cornea, iris and lens) imaging for any indication relating to refractive eye surgeries (eg, LASIK, laser eye surgery, etc.). As refractive surgeries may be excluded by certificate, any imaging done in conjunction would therefore not be a covered benefit if the surgery itself is not a covered benefit. In the absence of a certificate exclusion, this is considered not medically necessary as defined in the member’s individual certificate.

Additional information about eye conditions may be found from the following websites:

Background

  • American Academy of Ophthalmology
  • National Eye Institute
  • National Library of Medicine

Medical Alternatives

Alternatives to SCODI may vary by eye condition and include, but may not be limited to, the following:

  • Fluorescein angiography
  • Gonioscopy
  • Slit-lamp biomicroscopy
  • Stereoscopic fundus photography
  • Ultrasonography

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific