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1 Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (L35038) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Novitas Solutions, Inc. A and B MAC MAC A J - H Colorado Novitas Solutions, Inc. A and B MAC MAC B J - H Colorado Novitas Solutions, Inc. A and B MAC MAC A J - H New Mexico Novitas Solutions, Inc. A and B MAC MAC B J - H New Mexico Novitas Solutions, Inc. A and B MAC MAC A J - H Oklahoma Novitas Solutions, Inc. A and B MAC MAC B J - H Oklahoma Novitas Solutions, Inc. A and B MAC MAC A J - H Texas Novitas Solutions, Inc. A and B MAC MAC B J - H Texas Novitas Solutions, Inc. A and B MAC MAC A J - H Colorado New Mexico Oklahoma Texas Novitas Solutions, Inc. A and B MAC MAC A J - H Arkansas Novitas Solutions, Inc. A and B MAC MAC B J - H Arkansas Novitas Solutions, Inc. A and B MAC MAC A J - H Louisiana Novitas Solutions, Inc. A and B MAC MAC B J - H Louisiana Novitas Solutions, Inc. A and B MAC MAC A J - H Mississippi Novitas Solutions, Inc. A and B MAC MAC B J - H Mississippi Novitas Solutions, Inc. A and B MAC MAC A J - L Delaware Novitas Solutions, Inc. A and B MAC MAC B J - L Delaware Novitas Solutions, Inc. A and B MAC MAC A J - L District of Columbia Novitas Solutions, Inc. A and B MAC MAC B J - L District of Columbia Novitas Solutions, Inc. A and B MAC MAC A J - L Maryland Novitas Solutions, Inc. A and B MAC MAC B J - L Maryland Novitas Solutions, Inc. A and B MAC MAC A J - L New Jersey Novitas Solutions, Inc. A and B MAC MAC B J - L New Jersey Novitas Solutions, Inc. A and B MAC MAC A J - L Pennsylvania Novitas Solutions, Inc. A and B MAC MAC B J - L Pennsylvania Novitas Solutions, Inc. A and B MAC MAC A J - L District of Columbia Delaware Maryland New Jersey Pennsylvania Back to Top LCD Information Document Information LCD ID L35038 Original ICD-9 LCD ID L27529 Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2017 Printed on 10/6/2017. Page 1 of 37

2 LCD Title Scanning Computerized Ophthalmic Diagnostic Imaging Proposed LCD in Comment Period N/A Source Proposed LCD DL35038 AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for scanning computerized ophthalmic diagnostic imaging services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for scanning computerized ophthalmic diagnostic imaging services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: IOM Citations CMS IOM Publication , Medicare Claims Processing Manual, Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure codes. CMS IOM Publication , Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Correct Coding Initiative. Social Security Act (Title XVIII) Standard References Printed on 10/6/2017. Page 2 of 37

3 Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma also is diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range. Further, most patients having abnormally high pressures will never suffer glaucomatous damage to their vision. Glaucoma commonly causes a spectrum of related eye and vision changes, including erosion of the optic nerve and the associated retinal nerve fibers, and also loss of peripheral vision. A diagnosis of glaucoma seldom is made on the basis of a single clinical observation, but instead relies upon analysis of an assemblage of clinical data, including: optic nerve, retinal nerve fiber, and anterior chamber structure, as well as looking for hemorrhages of the optic nerve, pigment in the anterior chamber, and, especially visual field loss. Each of these methods has its own strengths and limitations, and none is immune to error thus the dependence upon multiple observations. Careful reliance upon all available clinical data can allow early treatment and can prevent unnecessary end-stage therapies. Scanning Computer Ophthalmic Diagnostic Imaging (SCODI) allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. Because SCODI detects glaucomatous damage to the nerve fiber layer or optic nerve of the eye, it can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure (IOP). It may separate patients with elevated IOP and early glaucoma damage from those without glaucoma. SCODI includes the following tests: Confocal Laser Scanning Ophthalmoscopy (topography) Scanning Laser Polarimetry, nerve fiber analyzer Optical Coherence Tomography (OCT) The two forms of scanning computerized ophthalmic diagnostic imaging tests that currently exist are confocal laser scanning ophthalmoscopy (topography) and scanning laser polarimetry. Although these techniques are different, their objective is the same in that they allow for early detection of glaucoma damage to the nerve fiber layer. Confocal scanning laser ophthalmoscopy (topography) uses stereoscopic videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina. Scanning laser polarimetry measures change in the linear polarization of light (retardation). It uses both a polarimeter (an optical device to measure linear polarization change) and a scanning laser ophthalmoscope, to measure the thickness of the nerve fiber layer of the retina. Printed on 10/6/2017. Page 3 of 37

4 In progressive glaucoma there is an increasing loss of retinal nerve fibers, therefore, a decrease in nerve fiber thickness occurs. Scanning computerized ophthalmic diagnostic imaging allows earlier detection of glaucoma and more sophisticated analysis for ongoing management. These tests can distinguish patients with glaucomatous damage irrespective of the status of the IOP. These tests also provide more precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of time than visual fields or disc photos. This allows earlier and more efficient efforts of treatment toward the disease process. Optical coherence tomography (OCT) is a non-invasive, non-contact imaging technique. OCT produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of retinal disease. Covered Indications 1. Glaucoma Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the nerve fiber even in advanced cases of glaucoma. It is expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma. 2. Retinal Disorders Retinal disorders are the most common causes of severe and permanent vision loss. These technologies are valuable tools for the evaluation and treatment of patients with retinal disease, especially macular abnormalities. These imaging techniques are useful tools to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of therapy. It is expected that only one exam/eye/2 months would be required to manage the patient whose primary ophthalmological condition is related to a retinal disease. However, for those patients who are undergoing active treatment for macular degeneration or diabetic retinopathy one exam/eye/month may be appropriate for the management of their disease. The use of fluorescein angiography, indocyanine green angiography and SCODI to study the patient's same eye per clinical encounter will NOT be authorized. However, SCODI and fluorescein angiography may be obtained on the patient's same eye per clinical encounter if the medical record substantiates the need for both studies. 3. Anterior Segment Disorders SCODI may be used to examine the structures in the anterior segment structures of the eye. However, it is still seen as experimental/investigational except in the following: Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction Iris tumor Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A- scan or IOL master. Certain exceptions that must be determined on a case-by-case basis with the appropriate documentation. Printed on 10/6/2017. Page 4 of 37

5 There is a need for monitoring patients on chloroquine (CQ) and hydroxychloroquine (HCQ) for the development of retinopathy during long-term therapy for rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). After the baseline evaluation, annual monitoring for toxicity should be initiated no later than 5 years after starting the medication (when the risk increases toward 1%). The patients receiving CQ or HCQ and their physicians must understand that rare cases of toxicity do occur earlier, such that more personalized risk stratification may prompt this need for earlier testing. Finally, where newer objective tests such as spectral domain (i.e., high resolution) optical coherence tomography are not available for such retinopathy monitoring, 10-2 automated visual field testing may need to suffice. Notice: This LCD imposes frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM , Chapter 13, Section , in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: Safe and effective. Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. Furnished in a setting appropriate to the patient's medical needs and condition. Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient's medical needs. At least as beneficial as an existing and available medically appropriate alternative. The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A Back to Top Coding Information Bill Type : Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Printed on 10/6/2017. Page 5 of 37

6 Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 999x Not Applicable Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Not Applicable CPT/HCPCS Group 1 Paragraph: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. Group 1 : Cmptr ophth img optic nerve Group 2 Paragraph: N/A Group 2 : Cptr ophth dx img post segmt Group 3 Paragraph: N/A Group 3 : Cmptr ophth dx img ant segmt ICD-10 that Support Medical Necessity Group 1 Paragraph: It is the provider s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. The following support the medical necessity of procedure code optic nerve: Group 1 : ICD-10 H Secondary noninfectious iridocyclitis, right eye H Secondary noninfectious iridocyclitis, left eye H Secondary noninfectious iridocyclitis, bilateral H Secondary noninfectious iridocyclitis, unspecified eye H Degeneration of iris (pigmentary), right eye H Degeneration of iris (pigmentary), left eye H Degeneration of iris (pigmentary), bilateral H Degeneration of iris (pigmentary), unspecified eye H21.40 Pupillary membranes, unspecified eye H21.41 Pupillary membranes, right eye H21.42 Pupillary membranes, left eye H21.43 Pupillary membranes, bilateral H Goniosynechiae, right eye H Goniosynechiae, left eye Printed on 10/6/2017. Page 6 of 37

7 H Goniosynechiae, bilateral H Goniosynechiae, unspecified eye H Recession of chamber angle, right eye H Recession of chamber angle, left eye H Recession of chamber angle, bilateral H Recession of chamber angle, unspecified eye H Preglaucoma, unspecified, right eye H Preglaucoma, unspecified, left eye H Preglaucoma, unspecified, bilateral H Preglaucoma, unspecified, unspecified eye H Open angle with borderline findings, low risk, right eye H Open angle with borderline findings, low risk, left eye H Open angle with borderline findings, low risk, bilateral H Open angle with borderline findings, low risk, unspecified eye H Open angle with borderline findings, high risk, right eye H Open angle with borderline findings, high risk, left eye H Open angle with borderline findings, high risk, bilateral H Open angle with borderline findings, high risk, unspecified eye H Anatomical narrow angle, right eye H Anatomical narrow angle, left eye H Anatomical narrow angle, bilateral H Anatomical narrow angle, unspecified eye H Steroid responder, right eye H Steroid responder, left eye H Steroid responder, bilateral H Steroid responder, unspecified eye H Ocular hypertension, right eye H Ocular hypertension, left eye H Ocular hypertension, bilateral H Ocular hypertension, unspecified eye H Primary angle closure without glaucoma damage, right eye H Primary angle closure without glaucoma damage, left eye H Primary angle closure without glaucoma damage, bilateral H Primary angle closure without glaucoma damage, unspecified eye H40.10X0 Unspecified open-angle glaucoma, stage unspecified H40.10X1 Unspecified open-angle glaucoma, mild stage H40.10X2 Unspecified open-angle glaucoma, moderate stage H40.10X3 Unspecified open-angle glaucoma, severe stage H40.10X4 Unspecified open-angle glaucoma, indeterminate stage H Primary open-angle glaucoma, right eye, stage unspecified H Primary open-angle glaucoma, right eye, mild stage H Primary open-angle glaucoma, right eye, moderate stage H Primary open-angle glaucoma, right eye, severe stage H Primary open-angle glaucoma, right eye, indeterminate stage H Primary open-angle glaucoma, left eye, stage unspecified H Primary open-angle glaucoma, left eye, mild stage H Primary open-angle glaucoma, left eye, moderate stage H Primary open-angle glaucoma, left eye, severe stage H Primary open-angle glaucoma, left eye, indeterminate stage H Primary open-angle glaucoma, bilateral, stage unspecified H Primary open-angle glaucoma, bilateral, mild stage H Primary open-angle glaucoma, bilateral, moderate stage H Primary open-angle glaucoma, bilateral, severe stage H Primary open-angle glaucoma, bilateral, indeterminate stage H Low-tension glaucoma, right eye, mild stage H Low-tension glaucoma, right eye, moderate stage H Low-tension glaucoma, right eye, severe stage Printed on 10/6/2017. Page 7 of 37

8 H Low-tension glaucoma, right eye, indeterminate stage H Low-tension glaucoma, left eye, mild stage H Low-tension glaucoma, left eye, moderate stage H Low-tension glaucoma, left eye, severe stage H Low-tension glaucoma, left eye, indeterminate stage H Low-tension glaucoma, bilateral, mild stage H Low-tension glaucoma, bilateral, moderate stage H Low-tension glaucoma, bilateral, severe stage H Low-tension glaucoma, bilateral, indeterminate stage H Low-tension glaucoma, unspecified eye, stage unspecified H Pigmentary glaucoma, right eye, mild stage H Pigmentary glaucoma, right eye, moderate stage H Pigmentary glaucoma, right eye, severe stage H Pigmentary glaucoma, right eye, indeterminate stage H Pigmentary glaucoma, left eye, mild stage H Pigmentary glaucoma, left eye, moderate stage H Pigmentary glaucoma, left eye, severe stage H Pigmentary glaucoma, left eye, indeterminate stage H Pigmentary glaucoma, bilateral, mild stage H Pigmentary glaucoma, bilateral, moderate stage H Pigmentary glaucoma, bilateral, severe stage H Pigmentary glaucoma, bilateral, indeterminate stage H Pigmentary glaucoma, unspecified eye, stage unspecified H Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage H Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage H Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage H Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, stage unspecified H Residual stage of open-angle glaucoma, right eye H Residual stage of open-angle glaucoma, left eye H Residual stage of open-angle glaucoma, bilateral H Residual stage of open-angle glaucoma, unspecified eye H40.20X0 Unspecified primary angle-closure glaucoma, stage unspecified H40.20X1 Unspecified primary angle-closure glaucoma, mild stage H40.20X2 Unspecified primary angle-closure glaucoma, moderate stage H40.20X3 Unspecified primary angle-closure glaucoma, severe stage H40.20X4 Unspecified primary angle-closure glaucoma, indeterminate stage H Acute angle-closure glaucoma, right eye H Acute angle-closure glaucoma, left eye H Acute angle-closure glaucoma, bilateral H Acute angle-closure glaucoma, unspecified eye H Chronic angle-closure glaucoma, right eye, stage unspecified H Chronic angle-closure glaucoma, right eye, mild stage H Chronic angle-closure glaucoma, right eye, moderate stage H Chronic angle-closure glaucoma, right eye, severe stage H Chronic angle-closure glaucoma, right eye, indeterminate stage H Chronic angle-closure glaucoma, left eye, stage unspecified H Chronic angle-closure glaucoma, left eye, mild stage H Chronic angle-closure glaucoma, left eye, moderate stage H Chronic angle-closure glaucoma, left eye, severe stage Printed on 10/6/2017. Page 8 of 37

9 H Chronic angle-closure glaucoma, left eye, indeterminate stage H Chronic angle-closure glaucoma, bilateral, stage unspecified H Chronic angle-closure glaucoma, bilateral, mild stage H Chronic angle-closure glaucoma, bilateral, moderate stage H Chronic angle-closure glaucoma, bilateral, severe stage H Chronic angle-closure glaucoma, bilateral, indeterminate stage H Chronic angle-closure glaucoma, unspecified eye, stage unspecified H Chronic angle-closure glaucoma, unspecified eye, mild stage H Chronic angle-closure glaucoma, unspecified eye, moderate stage H Chronic angle-closure glaucoma, unspecified eye, severe stage H Chronic angle-closure glaucoma, unspecified eye, indeterminate stage H Intermittent angle-closure glaucoma, right eye H Intermittent angle-closure glaucoma, left eye H Intermittent angle-closure glaucoma, bilateral H Intermittent angle-closure glaucoma, unspecified eye H Residual stage of angle-closure glaucoma, right eye H Residual stage of angle-closure glaucoma, left eye H Residual stage of angle-closure glaucoma, bilateral H Residual stage of angle-closure glaucoma, unspecified eye H40.30X0 Glaucoma secondary to eye trauma, unspecified eye, stage unspecified H40.30X1 Glaucoma secondary to eye trauma, unspecified eye, mild stage H40.30X2 Glaucoma secondary to eye trauma, unspecified eye, moderate stage H40.30X3 Glaucoma secondary to eye trauma, unspecified eye, severe stage H40.30X4 Glaucoma secondary to eye trauma, unspecified eye, indeterminate stage H40.31X0 Glaucoma secondary to eye trauma, right eye, stage unspecified H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage H40.32X0 Glaucoma secondary to eye trauma, left eye, stage unspecified H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage H40.33X0 Glaucoma secondary to eye trauma, bilateral, stage unspecified H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage H40.33X4 Glaucoma secondary to eye trauma, bilateral, indeterminate stage H40.40X0 Glaucoma secondary to eye inflammation, unspecified eye, stage unspecified H40.40X1 Glaucoma secondary to eye inflammation, unspecified eye, mild stage H40.40X2 Glaucoma secondary to eye inflammation, unspecified eye, moderate stage H40.40X3 Glaucoma secondary to eye inflammation, unspecified eye, severe stage H40.40X4 Glaucoma secondary to eye inflammation, unspecified eye, indeterminate stage H40.41X0 Glaucoma secondary to eye inflammation, right eye, stage unspecified H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage H40.41X2 Glaucoma secondary to eye inflammation, right eye, moderate stage H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage H40.41X4 Glaucoma secondary to eye inflammation, right eye, indeterminate stage H40.42X0 Glaucoma secondary to eye inflammation, left eye, stage unspecified H40.42X1 Glaucoma secondary to eye inflammation, left eye, mild stage H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage H40.42X3 Glaucoma secondary to eye inflammation, left eye, severe stage H40.42X4 Glaucoma secondary to eye inflammation, left eye, indeterminate stage H40.43X0 Glaucoma secondary to eye inflammation, bilateral, stage unspecified H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage Printed on 10/6/2017. Page 9 of 37

10 H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage H40.50X0 Glaucoma secondary to other eye disorders, unspecified eye, stage unspecified H40.50X1 Glaucoma secondary to other eye disorders, unspecified eye, mild stage H40.50X2 Glaucoma secondary to other eye disorders, unspecified eye, moderate stage H40.50X3 Glaucoma secondary to other eye disorders, unspecified eye, severe stage H40.50X4 Glaucoma secondary to other eye disorders, unspecified eye, indeterminate stage H40.51X0 Glaucoma secondary to other eye disorders, right eye, stage unspecified H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage H40.52X0 Glaucoma secondary to other eye disorders, left eye, stage unspecified H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage H40.53X0 Glaucoma secondary to other eye disorders, bilateral, stage unspecified H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage H40.60X0 Glaucoma secondary to drugs, unspecified eye, stage unspecified H40.60X1 Glaucoma secondary to drugs, unspecified eye, mild stage H40.60X2 Glaucoma secondary to drugs, unspecified eye, moderate stage H40.60X3 Glaucoma secondary to drugs, unspecified eye, severe stage H40.60X4 Glaucoma secondary to drugs, unspecified eye, indeterminate stage H40.61X0 Glaucoma secondary to drugs, right eye, stage unspecified H40.61X1 Glaucoma secondary to drugs, right eye, mild stage H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage H40.61X3 Glaucoma secondary to drugs, right eye, severe stage H40.61X4 Glaucoma secondary to drugs, right eye, indeterminate stage H40.62X0 Glaucoma secondary to drugs, left eye, stage unspecified H40.62X1 Glaucoma secondary to drugs, left eye, mild stage H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage H40.62X3 Glaucoma secondary to drugs, left eye, severe stage H40.62X4 Glaucoma secondary to drugs, left eye, indeterminate stage H40.63X0 Glaucoma secondary to drugs, bilateral, stage unspecified H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage H40.63X4 Glaucoma secondary to drugs, bilateral, indeterminate stage H Glaucoma with increased episcleral venous pressure, right eye H Glaucoma with increased episcleral venous pressure, left eye H Glaucoma with increased episcleral venous pressure, bilateral H Glaucoma with increased episcleral venous pressure, unspecified eye H Hypersecretion glaucoma, right eye H Hypersecretion glaucoma, left eye H Hypersecretion glaucoma, bilateral H Hypersecretion glaucoma, unspecified eye H Aqueous misdirection, right eye H Aqueous misdirection, left eye H Aqueous misdirection, bilateral H Aqueous misdirection, unspecified eye H40.89 Other specified glaucoma H40.9 Unspecified glaucoma H42 Glaucoma in diseases classified elsewhere H Ischemic optic neuropathy, right eye Printed on 10/6/2017. Page 10 of 37

11 H Ischemic optic neuropathy, left eye H Ischemic optic neuropathy, bilateral H Optic nerve hypoplasia, right eye H Optic nerve hypoplasia, left eye H Optic nerve hypoplasia, bilateral H47.10 Unspecified papilledema H47.11 Papilledema associated with increased intracranial pressure H47.12 Papilledema associated with decreased ocular pressure H47.13 Papilledema associated with retinal disorder H Foster-Kennedy syndrome, right eye H Foster-Kennedy syndrome, left eye H Foster-Kennedy syndrome, bilateral H Foster-Kennedy syndrome, unspecified eye H Glaucomatous optic atrophy, right eye H Glaucomatous optic atrophy, left eye H Glaucomatous optic atrophy, bilateral H Glaucomatous optic atrophy, unspecified eye H Other optic atrophy, right eye H Other optic atrophy, left eye H Other optic atrophy, bilateral H Other optic atrophy, unspecified eye H47.9 Unspecified disorder of visual pathways H Sudden visual loss, right eye H Sudden visual loss, left eye H Sudden visual loss, bilateral H Sudden visual loss, unspecified eye H53.15 Visual distortions of shape and size H Scotoma involving central area, right eye H Scotoma involving central area, left eye H Scotoma involving central area, bilateral H Scotoma involving central area, unspecified eye H Scotoma of blind spot area, right eye H Scotoma of blind spot area, left eye H Scotoma of blind spot area, bilateral H Scotoma of blind spot area, unspecified eye H Sector or arcuate defects, right eye H Sector or arcuate defects, left eye H Sector or arcuate defects, bilateral H Sector or arcuate defects, unspecified eye H Other localized visual field defect, right eye H Other localized visual field defect, left eye H Other localized visual field defect, bilateral H Other localized visual field defect, unspecified eye H Generalized contraction of visual field, right eye H Generalized contraction of visual field, left eye H Generalized contraction of visual field, bilateral H Generalized contraction of visual field, unspecified eye Q15.0 Congenital glaucoma T36.5X5A Adverse effect of aminoglycosides, initial encounter T36.5X5D Adverse effect of aminoglycosides, subsequent encounter T36.5X5S Adverse effect of aminoglycosides, sequela T36.8X5A Adverse effect of other systemic antibiotics, initial encounter T36.8X5D Adverse effect of other systemic antibiotics, subsequent encounter T36.8X5S Adverse effect of other systemic antibiotics, sequela T36.95XA Adverse effect of unspecified systemic antibiotic, initial encounter T36.95XD Adverse effect of unspecified systemic antibiotic, subsequent encounter T36.95XS Adverse effect of unspecified systemic antibiotic, sequela Printed on 10/6/2017. Page 11 of 37

12 T46.7X5A Adverse effect of peripheral vasodilators, initial encounter T46.7X5D Adverse effect of peripheral vasodilators, subsequent encounter T46.7X5S Adverse effect of peripheral vasodilators, sequela T48.6X5A Adverse effect of antiasthmatics, initial encounter T48.6X5D Adverse effect of antiasthmatics, subsequent encounter T48.6X5S Adverse effect of antiasthmatics, sequela Z03.6 Encounter for observation for suspected toxic effect from ingested substance ruled out Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z Long term (current) use of opiate analgesic Z Other long term (current) drug therapy Group 2 Paragraph: The following support the medical necessity of procedure code retina: Group 2 : ICD-10 B39.4 Histoplasmosis capsulati, unspecified C69.00 Malignant neoplasm of unspecified conjunctiva C69.01 Malignant neoplasm of right conjunctiva C69.02 Malignant neoplasm of left conjunctiva C69.20 Malignant neoplasm of unspecified retina C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.30 Malignant neoplasm of unspecified choroid C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid D18.09 Hemangioma of other sites D31.30 Benign neoplasm of unspecified choroid D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Printed on 10/6/2017. Page 12 of 37

13 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Printed on 10/6/2017. Page 13 of 37

14 E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Printed on 10/6/2017. Page 14 of 37

15 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Printed on 10/6/2017. Page 15 of 37