Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27497

Fluorescein and Indocyanine Green Angiography

L27497

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Fluorescein Angiography plays an important role in ophthalmoscopic diagnosis, especially the diagnosis and evaluation of many retinal conditions. Because it can precisely delineate areas of abnormality, it is an essential guide for planning laser treatment of retinal vascular disease. Following the intravascular administration of a contrast solution of sodium fluorescein, a blue light is used to excite the fluorescein which is useful in detecting leaking capillaries (subretinal neovascularization). A permanent record of the study is always made using either photographic or electronic imaging methods. Multiple black and white photographs of the ocular fundus at different times following fluorescein injection provides much information concerning vascular obstructions, neovascularization, microaneurysms, abnormal capillary permeability and defects of the retinal pigment epithelium.

Indocyanine green angiography (ICG) is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration.) Indocyanine green dye is injected intravenously into the patient to highlight the vessels in the retina and those of a deeper tissue layer called the choroid. The green dye fluoresces with infrared light. Photographs are then taken of the retina at intervals as increasing intensity of retinal and choroidal circulation is displayed.

Indications

Fluorescein Angiography

Fluorescein Angiography will be considered medically reasonable and necessary when the following conditions exist:

1. Initial evaluation of a patient with abnormal findings of the fundus/retina on an ophthalmoscopy exam, not limited to the following:
   • Choroidal Neovascular Membranes (CNVM)
   • Lesions of the Retinal Pigment Epithelium (RPE)
     • Serous detachment of the RPE;
     • Tears or rips of the RPE;
     • Hemorrhagic detachment.
   • Fibrovascular disciform scar
   • Vitreous hemorrhage - patient presents with complaints of sudden vision loss
   • Drusen
   • Diabetic retinopathy
     
     

2. Evaluation of a patient presenting with symptoms such as sudden vision loss, especially central vision, blurred vision, distortion, etc., which may suggest that a subretinal neovascularization is present.

3. Evaluation of patients with nonproliferative (background) and proliferative diabetic retinopathy with or without macular edema.
   
   
   • Background retinopathy is characterized by intraretinal microaneurysms, hemorrhages and hard exudates.
   • Proliferative retinopathy is characterized by neovascularization arising either from the disk or from the retinal vessels.

   The frequency of the fluorescein angiography is dependent on the extent of the disease progression and the treatment performed (i.e., photocoagulation). Fluorescein angiography may be performed as often as every 8 weeks to assist in management of the retinopathy.
   
   

4. Evaluation of patients with chorioretinitis, chorioretinal scars of choroidal degeneration, dystrophies, hemorrhage and rupture or detachment.
   
   

5. Evaluation of patients with known retinal or macular disorders such as:
   • Age-related macular degeneration (ARMD). ARMD is the leading cause of permanent blindness in the elderly. The disease includes a broad spectrum of clinical and pathologic findings that can be classified into two groups: nonexudative “dry” and exudative “wet”. The management of these two groups differ(s). Although patients with ARMD usually manifest nonexudative changes only, the majority of patients who experience severe vision loss from this disease do so from the development of subretinal neovascularization and related exudative maculopathy.
     • Examination after laser coagulation for exudative macular degeneration is performed at 1-2 weeks, 4 weeks, 6 weeks, then every 6 months unless new symptomatology (i.e., sudden central vision loss, distortion) and/or recurrence of subretinal neovascularization (as demonstrated by fluorescein) exists. If recurrent leakage is noted, laser therapy will be repeated, and the fluorescein angiography and fundus photography series will be repeated.
     • The nonexudative form of macular degeneration should have regular ophthalmic examinations. Fluorescein angiography may be performed every 6 months since the exudative stage may develop suddenly at any time even before patients demonstrate symptomatic visual problems.
   • Macular edema secondary to diabetic retinopathy
   • Cystoid Macular Edema
   • Central Retinal Vein Occlusion
   • Branch Retinal Vein Occlusion
   • Tumors of the choroid and retina
   • Retinal arterial disease
     

6. Evaluation of patients with ocular tumors, visual loss in systemic disease, and optic disc disease.

Indocyanine Green Angiography

Indocyanine green angiography (ICG) is a valuable diagnostic adjunct to fluorescein angiography in the evaluation of the following conditions:

• Retinal neovascularization
• Choroid neovascularization
• Serous detachment of retinal pigment epithelium
• Hemorrhagic detachment of retinal pigment epithelium
• Retinal hemorrhage

Limitations

Diagnostic Fluorescein Angiography performed in the absence of signs or symptoms is considered screening and is not a benefit of the Medicare program.

Indocyanine green angiography must be performed under the direct supervision of a physician when done by a non-physician practitioner.

New Jersey and New York State law excludes optometrists from performing invasive procedures, including ICG.

Indocyanine green is formulated with iodine and should not be used on patients who are allergic to iodine.

ICG for the evaluation of patients with background diabetic retinopathy is not a medically necessary service.

Following the performance of indocyanine green angiography, a fluorescein angiography will be considered medically unnecessary and not reimbursable when performed on the same eye, within a one month timeframe of the ICG. However, both procedures (i.e., ICG, FA) may be allowed on the same day. They (ICG and FA) are reimbursable on the same day only when additional diagnostic information is medically necessary. 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.

Generally only one ICG is medically necessary prior to and following a course of treatment. Services in excess of this standard of care must be reflected in the patients’ medical record, to support more frequent testing.

In the absence of pre-existing chronic disease, clinical signs or symptoms of disease, an ICG angiography is considered screening and is not a benefit of the Medicare program. Evidence of medical necessity must be documented in the medical record for each eye. A bilateral study is not automatically appropriate; in the absence of signs or symptoms a bilateral study would be considered screening.

An eye exam for the purposes of prescribing, fitting, or changing eyeglasses is not covered by the Medicare program.

Diagnostic Tests and X-Rays, Eye Care - Treatment of Macular Degeneration

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 Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Medical record documentation maintained by the performing physician must indicate the medical necessity of fluorescein angiography.  Office records/progress notes must document the complaint, symptomatology, or reasons necessitating the test and must include the examination results/findings.
   
   
5. Medical record documentation maintained by the performing physician must indicate the medical necessity of the indocyanine green angiography, (e.g., evidence of ill-defined subretinal neovascular membrane on fluorescein angiography). Office records/progress notes must document the complaint, symptomatology, or reasons necessitating the test and must include the examination results/findings.
   
   
6. The rationale for services provided in excess of the standard of care (one ICG prior to and one ICG following a course of treatment) must be reflected in the patients’ medical record to support more frequent testing.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27497

07/31/2008

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