All scanning computerized ophthalmic diagnostic imaging (SCODI) is divided into three procedures, one of which is confocal laser scanning ophthalmoscopy, scanning laser polarimetry another, optical coherence tomography, the third. All involve shining a narrow beam of light into the eye and using computers to construct cross-sectional tomographic images of structures in the eye, including the optic nerve head, nerve fiber layer, and retina. It can be used to assess the presence and progression of glaucoma and retinal disorders, as well as certain disorders of the anterior eye.

Clinical Guideline Coverage Criteria

The Plan considers scanning computerized ophthalmic diagnostic imaging (SCODI) as reasonable and medically necessary when ONE of the following indications are met:

1. For ONE of the following conditions at a maximum frequency of twice per year (per eye):
   • Glaucoma or suspected glaucoma and SCODI has not been performed more than once on a given eye in the past year; or
   • Visual field testing is inconclusive or impractical and SCODI has not been performed more than once on a given eye in the past year;
2. For ONE of the following conditions when a prior scan has not been performed more recently than two months, with each eye being counted separately:
   • Optic nerve disorder with uncertain identification/diagnosis and SCODI has not been performed on a given eye in the past two months; or
   • Ophthalmic conditions related to retinal disease, such as histoplasmosis or neoplasm, or malignant neoplasm or tuberculosis of the eye and SCODI has not been performed on a given eye in the past two months.
3. Presence of a discrepancy between clinical appearance of the optic nerve and visual fields; or
4. Presence or suspected presence of a magnetic foreign body in the body; or
5. Anterior segment disorders of the eye, comprising ONE of the following:
   • Narrow-angle, mixed narrow-angle, suspected narrow angle, and open-angle glaucoma; or
   • Corneal edema, ulcer, neoplasm, pterygium, or opacity precluding visualization of the anterior chamber; or
   • Need for cataract extraction or lens power calculation with history of prior refractive surgery; or
   • Treatment is planned for a disease affecting the cornea, iris, lens, or other anterior segment structure.
6. Treatment that requires monitoring (no more than monthly), specifically bevacizumab, aflibercept, pegaptanib sodium, dexamethasone, or ranibizumab for either diabetic retinopathy or macular degeneration; or
7. Long-term therapy with hydroxychloroquine and/or chloroquine when a prior scan has not been performed more recently than two months, with each eye being counted separately

Limitations

The Plan considers SCODI experimental/investigational for all other indications, including routine screening without indications.

Codes

The following code(s) are associated with this service

Table 1: CPT/HCPCS Codes

• Code 92133
• Code 92134

Description Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

List of Medically Necessary ICD-10 Codes: Harvard Pilgrim Health Care and Tufts Health Plan