LCD L33574

Coverage Guidance

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:

80.9 Computer Enhanced Perimetry.

Indications and Limitations of Coverage

Abstract:

Visual field testing detects defects in the field of vision, testing the function of the retina, optic nerve and optic pathways. Formal visual field tests are generally performed using automated perimetry, i.e., measurement of the ability to see points of light at varying locations on a curved surface.

Indications:

Visual field examinations are considered medically necessary for the conditions listed below:

• The patient has a disorder of the eyelid(s) potentially affecting the visual field(s).

• The patient has a visual field defect detected on gross visual field testing (e.g., confrontational testing).

• The patient has a documented diagnosis of glaucoma.

It should be noted that the progression of, and effects of treatment on glaucoma can be monitored only through periodic visual field testing. The frequency of such examinations is dependent on changes in intraocular pressure (IOP), retinal damage and changes at the optic disc.

• The patient is suspected of having glaucoma; signs include increased intraocular pressure, asymmetric IOP measurements, notching or thinning of the neuroretinal rim, splinter hemorrhages and asymmetric appearance of the discs.

• The patient has a documented disorder of the optic nerve, the retina or the neurologic visual pathway.

• The patient has a recent intracranial hemorrhage, an intracranial mass or a recent increased intracranial pressure measurement (with or without visual symptoms).

• The patient has a recent occlusion / stenosis of cerebral or precerebral arteries.

• The patient has a history of a cerebral aneurysm, pituitary or occipital tumor potentially affecting the visual fields.

• The patient is being evaluated for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.

• The patient has a disorder of the orbit potentially affecting the visual field.

• The patient has sustained a significant eye injury.

• The patient has unexplained visual loss.

• The patient has a pale or swollen optic nerve on a recent examination.

• The patient is having new functional limitations which may be due to visual field loss (e.g., reports by family of patient bumping into objects).

• The patient is taking a medication with a high risk of affecting the visual system (e.g., Plaquenil).

• The patient is being evaluated for macular degeneration, or has experienced central vision loss (< 20/70). (Repeated examinations for diagnosis of macular degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to evaluate the results of a surgical intervention).

Limitations:

Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological service and should not be reported separately.

Summary of Evidence

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Analysis of Evidence

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Bibliography

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