MEDICAL POLICY I. POLICY POLICY TITLE VISUAL FIELD TESTING POLICY NUMBER MP

Transcription

1 Original Issue Date (Created): 8/9/2002 Most Recent Review Date (Revised): 11/28/2017 Effective Date: 10/1/2018 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Automated visual field testing may be considered medically necessary for the following medical indications: Amblyopia; Benign or malignant neoplasm of the brain (including cranial nerves, cerebral meninges); Benign or malignant neoplasm of the eye (including orbit, lacrimal ducts, and conjunctiva); Buphthalmos; Cancer of the endocrine gland; Cancer of the eye; Cancer of the pituitary gland; Cerebral atherosclerosis; Cerebral infarction; Cerebrovascular disease; Choroidal degeneration; Congenital ptosis; Detached retina; Diabetes; Disorder of the optic chiasm; Disorder of the optic disc; Disorder of the optic nerve; Disorders of the retina; Endocrine disorders; Extradural hemorrhage; Focal chorioretinis; Giant cell arteritis; Glaucoma, Glaucoma Suspect Page 1

2 Inflammation of the eyelids; Injury to eye, optic nerves, or optic chiasm; Intracerebral hemorrhage; Intracranial hypertension; Late (tertiary) syphilis; Macular degeneration; Malignant neoplasm of the central nervous system; Migraines; Neurofibromatosis; Nystagmus; Occlusion or stenosis of cerebral arteries; Optic neuritis; Optic neuropathy; Papilledema; Paralytic strabismus; Ptosis of the eyelids; Toxic goiter with/without storm or crisis; Transient cerebral ischemia; Vitamin A deficiency; or Vitreous anomalies Automated visual field testing performed for any medical indication other than listed above, including screening of asymptomatic patients, is considered not medically necessary. Cross-reference: MP Blepharoplasty, Repair of Brow Ptosis and Reconstructive Eyelid Surgery II. PRODUCT VARIATIONS TOP This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. III. DESCRIPTION/BACKGROUND TOP Visual field testing is a procedure to detect loss of peripheral vision and provide a mapping of identified loss to aid in the diagnosis of the cause. There are several types of visual field testing including tangent screen testing, confrontation visual field exam, and automated perimetry. Visual field testing is usually performed to aid in the diagnosis or treatment of eye disorders and other diseases, or may be performed as part of a routine eye examination Page 2

3 IV. RATIONALE NA TOP V. DEFINITIONS TOP AUTOMATED PERIMETRY is a visual field exam in which the patient sits in front of a concave dome and stares at a central target within the dome. A computer-driven program flashes small lights at different locations within the dome s surface, and the patient presses a button when he/she sees the small lights in the peripheral vision. The responses are compared to agedmatched controls to determine the presence of defects within the visual field. CONFRONTATION VISUAL FIELD EXAM is a quick and basic evaluation of the visual field done by an examiner sitting directly in front of the patient. With one eye covered, the patient is asked to look at the examiner s eye and tell when he/she can see the examiner s hand. PERIPHERAL VISION is the capacity to see objects in the outer aspects of the field of use caused by reflected light waves that fall on areas of the retina distant from the macula. TANGENT SCREEN EXAM is a visual field exam where the patient sits about three feet from a screen with a target in the center. The patient is asked to stare at the central target and let the examiner know when he/she can see an object brought into the peripheral vision. VI. BENEFIT VARIATIONS TOP The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital BlueCross for benefit information. VII. DISCLAIMER TOP Capital BlueCross s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital Page 3

4 BlueCross considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. A50.6 Late congenital syphilis, latent A50.7 Late congenital syphilis, unspecified A52.14 Late syphilitic encephalitis A52.73 Symptomatic late syphilis of other respiratory organs A52.76 Other genitourinary symptomatic late syphilis A52.79 Other symptomatic late syphilis C69.40 Malignant neoplasm of unspecified ciliary body C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body C70.0 Malignant neoplasm of cerebral meninges C70.9 Malignant neoplasm of meninges, unspecified C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles C72.20 Malignant neoplasm of unspecified olfactory nerve C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve C72.30 Malignant neoplasm of unspecified optic nerve C72.31 Malignant neoplasm of right optic nerve C72.32 Malignant neoplasm of left optic nerve C72.40 Malignant neoplasm of unspecified acoustic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.50 Malignant neoplasm of unspecified cranial nerve C72.59 Malignant neoplasm of other cranial nerves C74.00 Malignant neoplasm of cortex of unspecified adrenal gland Page 4

5 C74.01 Malignant neoplasm of cortex of right adrenal gland C74.02 Malignant neoplasm of cortex of left adrenal gland C74.10 Malignant neoplasm of medulla of unspecified adrenal gland C74.11 Malignant neoplasm of medulla of right adrenal gland C74.12 Malignant neoplasm of medulla of left adrenal gland C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland C74.91 Malignant neoplasm of unspecified part of right adrenal gland C74.92 Malignant neoplasm of unspecified part of left adrenal gland C75.9 Malignant neoplasm of endocrine gland, unspecified C79.32 Secondary malignant neoplasm of cerebral meninges C79.40 Secondary malignant neoplasm of unspecified part of nervous system C79.49 Secondary malignant neoplasm of other parts of nervous system D09.20 Carcinoma in situ of unspecified eye D09.21 Carcinoma in situ of right eye D09.22 Carcinoma in situ of left eye D31.40 Benign neoplasm of unspecified ciliary body D31.41 Benign neoplasm of right ciliary body D31.42 Benign neoplasm of left ciliary body D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.2 Benign neoplasm of brain, unspecified D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.3 Neoplasm of uncertain behavior of pituitary gland D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct D49.6 Neoplasm of unspecified behavior of brain E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication 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 Page 5

6 E Type 2 diabetes mellitus with mild 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 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, right 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 without macular edema, right eye Page 6

7 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 E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema 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 E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E 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 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Page 7

8 E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E34.1 Other hypersecretion of intestinal hormones E34.8 Other specified endocrine disorders E35 Disorders of endocrine glands in diseases classified elsewhere E50.0 Vitamin A deficiency with conjunctival xerosis G Migraine with aura, not intractable, without status migrainosus G45.0 Vertebro-basilar artery syndrome G93.2 Benign intracranial hypertension H Unspecified blepharitis right upper eyelid H Unspecified blepharitis right lower eyelid H Unspecified blepharitis right eye, unspecified eyelid H Unspecified blepharitis left upper eyelid H Unspecified blepharitis left lower eyelid H Unspecified blepharitis left eye, unspecified eyelid H Unspecified blepharitis unspecified eye, unspecified eyelid H01.00A Unspecified blepharitis right eye, upper and lower eyelids H01.00B Unspecified blepharitis left eye, upper and lower eyelids H Ulcerative blepharitis right upper eyelid H Ulcerative blepharitis right lower eyelid H Ulcerative blepharitis right eye, unspecified eyelid H Ulcerative blepharitis left upper eyelid H Ulcerative blepharitis left lower eyelid H Ulcerative blepharitis left eye, unspecified eyelid Page 8

9 H Ulcerative blepharitis unspecified eye, unspecified eyelid H01.01A Ulcerative blepharitis right eye, upper and lower eyelids H01.01B Ulcerative blepharitis left eye, upper and lower eyelids H Squamous blepharitis right upper eyelid H Squamous blepharitis right lower eyelid H Squamous blepharitis right eye, unspecified eyelid H Squamous blepharitis left upper eyelid H Squamous blepharitis left lower eyelid H Squamous blepharitis left eye, unspecified eyelid H Squamous blepharitis unspecified eye, unspecified eyelid H01.02A Squamous blepharitis right eye, upper and lower eyelids H01.02B Squamous blepharitis left eye, upper and lower eyelids H Allergic dermatitis of right upper eyelid H Allergic dermatitis of right lower eyelid H Allergic dermatitis of right eye, unspecified eyelid H Allergic dermatitis of left upper eyelid H Allergic dermatitis of left lower eyelid H Allergic dermatitis of left eye, unspecified eyelid H Allergic dermatitis of unspecified eye, unspecified eyelid H Discoid lupus erythematosus of right upper eyelid H Discoid lupus erythematosus of right lower eyelid H Discoid lupus erythematosus of right eye, unspecified eyelid H Discoid lupus erythematosus of left upper eyelid H Discoid lupus erythematosus of left lower eyelid H Discoid lupus erythematosus of left eye, unspecified eyelid H Discoid lupus erythematosus of unspecified eye, unspecified eyelid H Eczematous dermatitis of right upper eyelid H Eczematous dermatitis of right lower eyelid H Eczematous dermatitis of right eye, unspecified eyelid H Eczematous dermatitis of left upper eyelid H Eczematous dermatitis of left lower eyelid H Eczematous dermatitis of left eye, unspecified eyelid H Eczematous dermatitis of unspecified eye, unspecified eyelid H Xeroderma of right upper eyelid H Xeroderma of right lower eyelid H Xeroderma of right eye, unspecified H Xeroderma of left upper eyelid H Xeroderma of left lower eyelid Page 9

10 H Xeroderma of left eye, unspecified eyelid H Xeroderma of unspecified eye, unspecified eyelid H02.30 Blepharochalasis unspecified eye, unspecified eyelid H02.31 Blepharochalasis right upper eyelid H02.32 Blepharochalasis right lower eyelid H02.33 Blepharochalasis right eye, unspecified eyelid H02.34 Blepharochalasis left upper eyelid H02.35 Blepharochalasis left lower eyelid H02.36 Blepharochalasis left eye, unspecified eyelid H Unspecified ptosis of right eyelid H Unspecified ptosis of left eyelid H Unspecified ptosis of bilateral eyelids H Unspecified ptosis of unspecified eyelid H Mechanical ptosis of right eyelid H Mechanical ptosis of left eyelid H Mechanical ptosis of bilateral eyelids H Mechanical ptosis of unspecified eyelid H Myogenic ptosis of right eyelid H Myogenic ptosis of left eyelid H Myogenic ptosis of bilateral eyelids H Myogenic ptosis of unspecified eyelid H Paralytic ptosis of right eyelid H Paralytic ptosis of left eyelid H Paralytic ptosis of bilateral eyelids H Paralytic ptosis unspecified eyelid H Dermatochalasis of right upper eyelid H Dermatochalasis of right lower eyelid H Dermatochalasis of right eye, unspecified eyelid H Dermatochalasis of left upper eyelid H Dermatochalasis of left lower eyelid H Dermatochalasis of left eye, unspecified eyelid H Dermatochalasis of unspecified eye, unspecified eyelid H05.89 Other disorders of orbit H Unspecified focal chorioretinal inflammation, right eye H Unspecified focal chorioretinal inflammation, left eye H Unspecified focal chorioretinal inflammation, bilateral H Unspecified focal chorioretinal inflammation, unspecified eye H Unspecified retinal detachment with retinal break, right eye Page 10

11 H Unspecified retinal detachment with retinal break, left eye H Unspecified retinal detachment with retinal break, bilateral H Unspecified retinal detachment with retinal break, unspecified eye H Retinal detachment with single break, right eye H Retinal detachment with single break, left eye H Retinal detachment with single break, bilateral H Retinal detachment with single break, unspecified eye H Retinal detachment with multiple breaks, right eye H Retinal detachment with multiple breaks, left eye H Retinal detachment with multiple breaks, bilateral H Retinal detachment with multiple breaks, unspecified eye H Retinal detachment with giant retinal tear, right eye H Retinal detachment with giant retinal tear, left eye H Retinal detachment with giant retinal tear, bilateral H Retinal detachment with giant retinal tear, unspecified eye H Retinal detachment with retinal dialysis, right eye H Retinal detachment with retinal dialysis, left eye H Retinal detachment with retinal dialysis, bilateral H Retinal detachment with retinal dialysis, unspecified eye H Total retinal detachment, right eye H Total retinal detachment, left eye H Total retinal detachment, bilateral H Total retinal detachment, unspecified eye H Unspecified retinoschisis, right eye H Unspecified retinoschisis, left eye H Unspecified retinoschisis, bilateral H Unspecified retinoschisis, unspecified eye H Cyst of ora serrata, right eye H Cyst of ora serrata, left eye H Cyst of ora serrata, bilateral H Cyst of ora serrata, unspecified eye H Other retinoschisis and retinal cysts, right eye H Other retinoschisis and retinal cysts, left eye H Other retinoschisis and retinal cysts, bilateral H Other retinoschisis and retinal cysts, unspecified eye H33.40 Traction detachment of retina, unspecified eye H33.41 Traction detachment of retina, right eye H33.42 Traction detachment of retina, left eye Page 11

12 H33.43 Traction detachment of retina, bilateral H33.8 Other retinal detachments H34.9 Unspecified retinal vascular occlusion H Preglaucoma, unspecified, right eye H Preglaucoma, unspecified, left eye H Preglaucoma, unspecified, bilateral 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, high risk, right eye H Open angle with borderline findings, high risk, left eye H Open angle with borderline findings, high risk, bilateral H Anatomical narrow angle, right eye H Anatomical narrow angle, left eye H Anatomical narrow angle, bilateral H Steroid responder, right eye H Steroid responder, left eye H Steroid responder, bilateral H Ocular hypertension, right eye H Ocular hypertension, left eye H Ocular hypertension, bilateral 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 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 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, 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, mild stage H Primary open-angle glaucoma, bilateral, moderate stage Page 12

13 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 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, mild stage H Low-tension glaucoma, unspecified eye, moderate stage H Low-tension glaucoma, unspecified eye, severe stage 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, mild stage H Pigmentary glaucoma, unspecified eye, moderate stage H Pigmentary glaucoma, unspecified eye, severe stage 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 Page 13

14 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, mild stage H Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, severe stage 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 H40.20X1 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 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, 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, mild stage H Chronic angle-closure glaucoma, left eye, moderate stage H Chronic angle-closure glaucoma, left eye, severe stage H Chronic angle-closure glaucoma, left eye, indeterminate stage 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, mild stage H Chronic angle-closure glaucoma, unspecified eye, moderate stage H Chronic angle-closure glaucoma, unspecified eye, severe stage H Intermittent angle-closure glaucoma, right eye H Intermittent angle-closure glaucoma, left eye H Intermittent angle-closure glaucoma Page 14

15 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 H40.31X1 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 H40.32X1 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 H40.33X1 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 H40.40X1 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 H40.41X1 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 H40.42X1 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 stag H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage H40.50X1 Glaucoma secondary to other eye disorders, unspecified eye, mild stage H40.50X2 Glaucoma secondary to other eye disorders, unspecified eye, moderate stag Page 15

16 H40.50X3 Glaucoma secondary to other eye disorders, unspecified eye, severe stage 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 H40.52X1 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 H40.53X1 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 H40.60X1 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 H40.61X1 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 H40.62X1 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 H40.63X1 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 Page 16

17 H Aqueous misdirection, bilateral H Aqueous misdirection, unspecified eye H40.89 Other specified glaucoma H40.9 Unspecified glaucoma H42 Glaucoma in diseases classified elsewhere H44.2A1 Degenerative myopia with choroidal neovascularization, right eye H44.2A2 Degenerative myopia with choroidal neovascularization, left eye H44.2A3 Degenerative myopia with choroidal neovascularization, bilateral eye H44.2A9 Degenerative myopia with choroidal neovascularization, unspecified eye H44.2B1 Degenerative myopia with macular hole, right eye H44.2B2 Degenerative myopia with macular hole, left eye H44.2B3 Degenerative myopia with macular hole, left eye H44.2B9 Degenerative myopia with macular hole, unspecified eye H44.2C1 H44.2C2 H44.2C3 H44.2C9 H44.2D1 H44.2D2 H44.2D3 Degenerative myopia with retinal detachment, right eye Degenerative myopia with retinal detachment, left eye Degenerative myopia with retinal detachment, bilateral eye Degenerative myopia with retinal detachment, unspecified eye Degenerative myopia with foveoschisis, right eye Degenerative myopia with foveoschisis, left eye Degenerative myopia with foveoschisis, bilateral eye H44.2D9 Degenerative myopia with foveoschisis, unspecified eye H44.2E1 Degenerative myopia with other maculopathy, right eye H44.2E2 Degenerative myopia with other maculopathy, left eye H44.2E3 Degenerative myopia with other maculopathy, bilateral eye H44.2E9 Degenerative myopia with other maculopathy, unspecified eye H Siderosis of eye, right eye H Siderosis of eye, left eye H Siderosis of eye, bilateral H Siderosis of eye, unspecified eye H Other degenerative disorders of globe, right eye H Other degenerative disorders of globe, left eye H Other degenerative disorders of globe, bilateral H Other degenerative disorders of globe, unspecified eye 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 Page 17

18 H Foster-Kennedy syndrome, left eye H Foster-Kennedy syndrome, bilateral H Foster-Kennedy syndrome, unspecified eye H Other paralytic strabismus, right eye H Other paralytic strabismus, left eye H Other paralytic strabismus, bilateral H Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H51.0 Palsy (spasm) of conjugate gaze H Unspecified amblyopia, right eye H Unspecified amblyopia, left eye H Unspecified amblyopia, bilateral H Unspecified amblyopia, unspecified eye H Deprivation amblyopia, right eye H Deprivation amblyopia, left eye H Deprivation amblyopia, bilateral H Deprivation amblyopia, unspecified eye H Refractive amblyopia, right eye H Refractive amblyopia, left eye H Refractive amblyopia, bilateral H Refractive amblyopia, unspecified eye H Strabismic amblyopia, right eye H Strabismic amblyopia, left eye H Strabismic H Strabismic amblyopia, unspecified eye H53.10 Unspecified subjective visual disturbances H53.11 Day blindness H53.40 Unspecified visual field defects 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 Page 18

19 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 H Homonymous bilateral field defects, right side H Homonymous bilateral field defects, left side H Homonymous bilateral field defects, unspecified side H53.47 Heteronymous bilateral field defects 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 H53.60 Unspecified night blindness H54.0X33 Blindness right eye category 3, blindness left eye category 3 H54.0X34 Blindness right eye category 3, blindness left eye category 4 H54.0X35 Blindness right eye category 3, blindness left eye category 5 H54.0X43 Blindness right eye category 4, blindness left eye category 3 H54.0X44 Blindness right eye category 4, blindness left eye category 4 H54.0X45 Blindness right eye category 4, blindness left eye category 5 H54.0X53 Blindness right eye category 5, blindness left eye category 3 H54.0X54 Blindness right eye category 5, blindness left eye category 4 H54.0X55 Blindness right eye category 5, blindness left eye category 5 H55.00 Unspecified nystagmus H Brow ptosis, right H Brow ptosis, left H Brow ptosis, bilateral H Brow ptosis, unspecified H57.89 Other specified disorders of eye and adnexa I62.1 Nontraumatic extradural hemorrhage I63.02 Cerebral infarction due to thrombosis of basilar artery I63.12 Cerebral infarction due to embolism of basilar artery I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries I65.1 Occlusion and stenosis of basilar artery I67.81 Acute cerebrovascular insufficiency I67.82 Cerebral ischemia I67.83 Posterior reversible encephalopathy syndrome Page 19

20 I Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy I Other hereditary cerebrovascular disease M31.5 Giant cell arteritis with polymyalgia rheumatica M31.6 Other giant cell arteritis Q10.0 Congenital ptosis Q14.0 Congenital malformation of vitreous humor Q15.0 Congenital glaucoma Q85.00 Neurofibromatosis, unspecified Q85.01 Neurofibromatosis, type 1 Q85.02 Neurofibromatosis, type 2 Q85.03 Schwannomatosis Q85.09 Other neurofibromatosis S00.10XA Contusion of unspecified eyelid and periocular area, initial encounter S00.11XA Contusion of right eyelid and periocular area, initial encounter S00.12XA Contusion of left eyelid and periocular area, initial encounter S00.201A Unspecified superficial injury of right eyelid and periocular area, initial encounter S00.202A Unspecified superficial injury of left eyelid and periocular area, initial encounter S00.209A Unspecified superficial injury of unspecified eyelid and periocular area, initial encounter S00.211A Abrasion of right eyelid and periocular area, initial encounter S00.212A Abrasion of left eyelid and periocular area, initial encounter S00.219A Abrasion of unspecified eyelid and periocular area, initial encounter S00.221A Blister (nonthermal) of right eyelid and periocular area, initial encounter S00.222A Blister (nonthermal) of left eyelid and periocular area, initial encounter S00.229A Blister (nonthermal) of unspecified eyelid and periocular area, initial encounter S00.241A External constriction of right eyelid and periocular area, initial encounter S00.242A External constriction of left eyelid and periocular area, initial encounter S00.249A External constriction of unspecified eyelid and periocular area, initial encounter S00.251A Superficial foreign body of right eyelid and periocular area, initial encounter S00.252A Superficial foreign body of left eyelid and periocular area, initial encounter S00.259A Superficial foreign body of unspecified eyelid and periocular area, initial encounter S00.261A Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter S00.262A Insect bite (nonvenomous) of left eyelid and periocular area, initial encounter S00.269A Insect bite (nonvenomous) of unspecified eyelid and periocular area, initial encounter S00.271A Other superficial bite of right eyelid and periocular area, initial encounter S00.272A Other superficial bite of left eyelid and periocular area, initial encounter S00.279A Other superficial bite of unspecified eyelid and periocular area, initial encounter S01.101A Unspecified open wound of right eyelid and periocular area, initial encounter Page 20

21 Diagnosis S01.102A S01.109A S04.011A S04.012A S04.019A S04.10XA S04.11XA S04.12XA S04.40XA S04.41XA S04.42XA S05.30XA S05.31XA S05.32XA Z09 Description Unspecified open wound of left eyelid and periocular area, initial Unspecified open wound of unspecified eyelid and periocular area, initial encounter Injury of optic nerve, right eye, initial encounter Injury of optic nerve, left eye, initial encounter Injury of optic nerve, unspecified eye, initial encounter Injury of oculomotor nerve, unspecified side, initial encounter Injury of oculomotor nerve, right side, initial encounter Injury of oculomotor nerve, left side, initial encounter Injury of abducent nerve, unspecified side, initial encounter Injury of abducent nerve, right side, initial encounter Injury of abducent nerve, left side, initial encounter Ocular laceration without prolapse or loss of intraocular tissue, unspecified eye, initial encounter Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter 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 IX. REFERENCES TOP Henderer, Jeffrey MD. Understanding Visual Field Test Taking Glaucoma Service Foundation to Prevent Blindness [Website]: Accessed May 18, Jacobs DS. Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis.. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; Updated January 22, [Website] : Accessed May 18, Medline plus Medical Encyclopedia: Visual Field: Updated 2/23/15. [Website]: Accessed May 18, Mosby s Medical, Nursing, & Allied Health Dictionary, 6 th edition. National Guideline Clearinghouse- Screening for Glaucoma: U.S. Preventive Services Task Force Recommendation Statement, Revised 10/1/13. AHRQ[Website]: Accessed May 18, Page 21

22 X. POLICY HISTORY TOP MP CAC 6/29/04 CAC 12/14/04 CAC 9/27/05 CAC 6/27/06 CAC 7/31/07 CAC 7/29/08 and J12 MAC 12/12/08 CAC 7/28/09 Consensus Review CAC 11/30/10 Consensus review. CAC 4/24/12 Consensus review. Changed Sr. Blue variation reference from Highmark Medicare Service to Novitas Solutions Inc. Removed benefit information. References updated. 04/5/2013- Policy codes reviewed CAC-6/4/13 Consensus review. 1/2014 Removed retired Novitas Solutions, Inc. Local Coverage Determination L27545, Visual Fields. Screening for covered indications. CAC 3/25/14 Consensus. Added Medicare variation to NCD 80.9 Computer Enhanced Perimetry. No change to policy statements. References updated. CAC 3/24/15 Consensus review. No changes to the policy statements. References updated. Coding reviewed. CAC 11/29/16 Consensus review. No change to policy statements. References updated. Variation reformatting. Coding reviewed. Admin update 10/1/17: Added new ICD 10 codes effective from 10/1/17 and deleted old ICD 10 codes. CAC 11/28/17 Consensus review. References reviewed. Coding reviewed. Medicare information removed from commercial policies. 10/1/18 Admin Update: Removed deleted ICD-10 codes, added new ICD- 10 codes effective 10/1/18. Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 22