Contractor Information

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 04111 - MAC A J - H Colorado Novitas Solutions, Inc. A and B MAC 04112 - MAC B J - H Colorado Novitas Solutions, Inc. A and B MAC 04211 - MAC A J - H New Mexico Novitas Solutions, Inc. A and B MAC 04212 - MAC B J - H New Mexico Novitas Solutions, Inc. A and B MAC 04311 - MAC A J - H Oklahoma Novitas Solutions, Inc. A and B MAC 04312 - MAC B J - H Oklahoma Novitas Solutions, Inc. A and B MAC 04411 - MAC A J - H Texas Novitas Solutions, Inc. A and B MAC 04412 - MAC B J - H Texas Novitas Solutions, Inc. A and B MAC 04911 - MAC A J - H Colorado New Mexico Oklahoma Texas Novitas Solutions, Inc. A and B MAC 07101 - MAC A J - H Arkansas Novitas Solutions, Inc. A and B MAC 07102 - MAC B J - H Arkansas Novitas Solutions, Inc. A and B MAC 07201 - MAC A J - H Louisiana Novitas Solutions, Inc. A and B MAC 07202 - MAC B J - H Louisiana Novitas Solutions, Inc. A and B MAC 07301 - MAC A J - H Mississippi Novitas Solutions, Inc. A and B MAC 07302 - MAC B J - H Mississippi Novitas Solutions, Inc. A and B MAC 12101 - MAC A J - L Delaware Novitas Solutions, Inc. A and B MAC 12102 - MAC B J - L Delaware Novitas Solutions, Inc. A and B MAC 12201 - MAC A J - L District of Columbia Novitas Solutions, Inc. A and B MAC 12202 - MAC B J - L District of Columbia Novitas Solutions, Inc. A and B MAC 12301 - MAC A J - L Maryland Novitas Solutions, Inc. A and B MAC 12302 - MAC B J - L Maryland Novitas Solutions, Inc. A and B MAC 12401 - MAC A J - L New Jersey Novitas Solutions, Inc. A and B MAC 12402 - MAC B J - L New Jersey Novitas Solutions, Inc. A and B MAC 12501 - MAC A J - L Pennsylvania Novitas Solutions, Inc. A and B MAC 12502 - MAC B J - L Pennsylvania Novitas Solutions, Inc. A and B MAC 12901 - 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

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 2002-2017 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 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure codes. CMS IOM Publication 100-09, 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

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

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

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 100-08, Chapter 13, Section 13.5.1, 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

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. 99999 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 : 92133 Cmptr ophth img optic nerve Group 2 Paragraph: N/A Group 2 : 92134 Cptr ophth dx img post segmt Group 3 Paragraph: N/A Group 3 : 92132 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 92133 - optic nerve: Group 1 : ICD-10 H20.041 Secondary noninfectious iridocyclitis, right eye H20.042 Secondary noninfectious iridocyclitis, left eye H20.043 Secondary noninfectious iridocyclitis, bilateral H20.049 Secondary noninfectious iridocyclitis, unspecified eye H21.231 Degeneration of iris (pigmentary), right eye H21.232 Degeneration of iris (pigmentary), left eye H21.233 Degeneration of iris (pigmentary), bilateral H21.239 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 H21.521 Goniosynechiae, right eye H21.522 Goniosynechiae, left eye Printed on 10/6/2017. Page 6 of 37

H21.523 Goniosynechiae, bilateral H21.529 Goniosynechiae, unspecified eye H21.551 Recession of chamber angle, right eye H21.552 Recession of chamber angle, left eye H21.553 Recession of chamber angle, bilateral H21.559 Recession of chamber angle, unspecified eye H40.001 Preglaucoma, unspecified, right eye H40.002 Preglaucoma, unspecified, left eye H40.003 Preglaucoma, unspecified, bilateral H40.009 Preglaucoma, unspecified, unspecified eye H40.011 Open angle with borderline findings, low risk, right eye H40.012 Open angle with borderline findings, low risk, left eye H40.013 Open angle with borderline findings, low risk, bilateral H40.019 Open angle with borderline findings, low risk, unspecified eye H40.021 Open angle with borderline findings, high risk, right eye H40.022 Open angle with borderline findings, high risk, left eye H40.023 Open angle with borderline findings, high risk, bilateral H40.029 Open angle with borderline findings, high risk, unspecified eye H40.031 Anatomical narrow angle, right eye H40.032 Anatomical narrow angle, left eye H40.033 Anatomical narrow angle, bilateral H40.039 Anatomical narrow angle, unspecified eye H40.041 Steroid responder, right eye H40.042 Steroid responder, left eye H40.043 Steroid responder, bilateral H40.049 Steroid responder, unspecified eye H40.051 Ocular hypertension, right eye H40.052 Ocular hypertension, left eye H40.053 Ocular hypertension, bilateral H40.059 Ocular hypertension, unspecified eye H40.061 Primary angle closure without glaucoma damage, right eye H40.062 Primary angle closure without glaucoma damage, left eye H40.063 Primary angle closure without glaucoma damage, bilateral H40.069 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 H40.1110 Primary open-angle glaucoma, right eye, stage unspecified H40.1111 Primary open-angle glaucoma, right eye, mild stage H40.1112 Primary open-angle glaucoma, right eye, moderate stage H40.1113 Primary open-angle glaucoma, right eye, severe stage H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage H40.1120 Primary open-angle glaucoma, left eye, stage unspecified H40.1121 Primary open-angle glaucoma, left eye, mild stage H40.1122 Primary open-angle glaucoma, left eye, moderate stage H40.1123 Primary open-angle glaucoma, left eye, severe stage H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified H40.1131 Primary open-angle glaucoma, bilateral, mild stage H40.1132 Primary open-angle glaucoma, bilateral, moderate stage H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage H40.1211 Low-tension glaucoma, right eye, mild stage H40.1212 Low-tension glaucoma, right eye, moderate stage H40.1213 Low-tension glaucoma, right eye, severe stage Printed on 10/6/2017. Page 7 of 37

H40.1214 Low-tension glaucoma, right eye, indeterminate stage H40.1221 Low-tension glaucoma, left eye, mild stage H40.1222 Low-tension glaucoma, left eye, moderate stage H40.1223 Low-tension glaucoma, left eye, severe stage H40.1224 Low-tension glaucoma, left eye, indeterminate stage H40.1231 Low-tension glaucoma, bilateral, mild stage H40.1232 Low-tension glaucoma, bilateral, moderate stage H40.1233 Low-tension glaucoma, bilateral, severe stage H40.1234 Low-tension glaucoma, bilateral, indeterminate stage H40.1290 Low-tension glaucoma, unspecified eye, stage unspecified H40.1311 Pigmentary glaucoma, right eye, mild stage H40.1312 Pigmentary glaucoma, right eye, moderate stage H40.1313 Pigmentary glaucoma, right eye, severe stage H40.1314 Pigmentary glaucoma, right eye, indeterminate stage H40.1321 Pigmentary glaucoma, left eye, mild stage H40.1322 Pigmentary glaucoma, left eye, moderate stage H40.1323 Pigmentary glaucoma, left eye, severe stage H40.1324 Pigmentary glaucoma, left eye, indeterminate stage H40.1331 Pigmentary glaucoma, bilateral, mild stage H40.1332 Pigmentary glaucoma, bilateral, moderate stage H40.1333 Pigmentary glaucoma, bilateral, severe stage H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage H40.1390 Pigmentary glaucoma, unspecified eye, stage unspecified H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage H40.1490 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, stage unspecified H40.151 Residual stage of open-angle glaucoma, right eye H40.152 Residual stage of open-angle glaucoma, left eye H40.153 Residual stage of open-angle glaucoma, bilateral H40.159 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 H40.211 Acute angle-closure glaucoma, right eye H40.212 Acute angle-closure glaucoma, left eye H40.213 Acute angle-closure glaucoma, bilateral H40.219 Acute angle-closure glaucoma, unspecified eye H40.2210 Chronic angle-closure glaucoma, right eye, stage unspecified H40.2211 Chronic angle-closure glaucoma, right eye, mild stage H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage H40.2213 Chronic angle-closure glaucoma, right eye, severe stage H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage H40.2220 Chronic angle-closure glaucoma, left eye, stage unspecified H40.2221 Chronic angle-closure glaucoma, left eye, mild stage H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage H40.2223 Chronic angle-closure glaucoma, left eye, severe stage Printed on 10/6/2017. Page 8 of 37

H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage H40.2230 Chronic angle-closure glaucoma, bilateral, stage unspecified H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage H40.2290 Chronic angle-closure glaucoma, unspecified eye, stage unspecified H40.2291 Chronic angle-closure glaucoma, unspecified eye, mild stage H40.2292 Chronic angle-closure glaucoma, unspecified eye, moderate stage H40.2293 Chronic angle-closure glaucoma, unspecified eye, severe stage H40.2294 Chronic angle-closure glaucoma, unspecified eye, indeterminate stage H40.231 Intermittent angle-closure glaucoma, right eye H40.232 Intermittent angle-closure glaucoma, left eye H40.233 Intermittent angle-closure glaucoma, bilateral H40.239 Intermittent angle-closure glaucoma, unspecified eye H40.241 Residual stage of angle-closure glaucoma, right eye H40.242 Residual stage of angle-closure glaucoma, left eye H40.243 Residual stage of angle-closure glaucoma, bilateral H40.249 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

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 H40.811 Glaucoma with increased episcleral venous pressure, right eye H40.812 Glaucoma with increased episcleral venous pressure, left eye H40.813 Glaucoma with increased episcleral venous pressure, bilateral H40.819 Glaucoma with increased episcleral venous pressure, unspecified eye H40.821 Hypersecretion glaucoma, right eye H40.822 Hypersecretion glaucoma, left eye H40.823 Hypersecretion glaucoma, bilateral H40.829 Hypersecretion glaucoma, unspecified eye H40.831 Aqueous misdirection, right eye H40.832 Aqueous misdirection, left eye H40.833 Aqueous misdirection, bilateral H40.839 Aqueous misdirection, unspecified eye H40.89 Other specified glaucoma H40.9 Unspecified glaucoma H42 Glaucoma in diseases classified elsewhere H47.011 Ischemic optic neuropathy, right eye Printed on 10/6/2017. Page 10 of 37

H47.012 Ischemic optic neuropathy, left eye H47.013 Ischemic optic neuropathy, bilateral H47.031 Optic nerve hypoplasia, right eye H47.032 Optic nerve hypoplasia, left eye H47.033 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 H47.141 Foster-Kennedy syndrome, right eye H47.142 Foster-Kennedy syndrome, left eye H47.143 Foster-Kennedy syndrome, bilateral H47.149 Foster-Kennedy syndrome, unspecified eye H47.231 Glaucomatous optic atrophy, right eye H47.232 Glaucomatous optic atrophy, left eye H47.233 Glaucomatous optic atrophy, bilateral H47.239 Glaucomatous optic atrophy, unspecified eye H47.291 Other optic atrophy, right eye H47.292 Other optic atrophy, left eye H47.293 Other optic atrophy, bilateral H47.299 Other optic atrophy, unspecified eye H47.9 Unspecified disorder of visual pathways H53.131 Sudden visual loss, right eye H53.132 Sudden visual loss, left eye H53.133 Sudden visual loss, bilateral H53.139 Sudden visual loss, unspecified eye H53.15 Visual distortions of shape and size H53.411 Scotoma involving central area, right eye H53.412 Scotoma involving central area, left eye H53.413 Scotoma involving central area, bilateral H53.419 Scotoma involving central area, unspecified eye H53.421 Scotoma of blind spot area, right eye H53.422 Scotoma of blind spot area, left eye H53.423 Scotoma of blind spot area, bilateral H53.429 Scotoma of blind spot area, unspecified eye H53.431 Sector or arcuate defects, right eye H53.432 Sector or arcuate defects, left eye H53.433 Sector or arcuate defects, bilateral H53.439 Sector or arcuate defects, unspecified eye H53.451 Other localized visual field defect, right eye H53.452 Other localized visual field defect, left eye H53.453 Other localized visual field defect, bilateral H53.459 Other localized visual field defect, unspecified eye H53.481 Generalized contraction of visual field, right eye H53.482 Generalized contraction of visual field, left eye H53.483 Generalized contraction of visual field, bilateral H53.489 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

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 Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Group 2 Paragraph: The following support the medical necessity of procedure code 92134 - 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 E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E08.3392 Printed on 10/6/2017. Page 12 of 37

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Printed on 10/6/2017. Page 13 of 37

E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E11.3291 Printed on 10/6/2017. Page 14 of 37

Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Printed on 10/6/2017. Page 15 of 37