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Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma

Policy Number: MP-465

Latest Review Date: March 2020

Category: Medical                                                                 

Policy Grade: C

POLICY:

Analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography.  (This test is usually not considered medically necessary more than one per 12 months.)

Measurement of ocular blood flow, pulsatile ocular blood flow or blood flow velocity with Doppler ultrasonography is considered not medically necessary and investigational in the diagnosis and follow-up of patients with glaucoma.

DESCRIPTION OF PROCEDURE OR SERVICE:

Several techniques have been developed to measure the thickness of the optic nerve/retinal nerve fiber layer (RNFL) as a method to diagnose and monitor glaucoma. Measurement of ocular blood flow is also being evaluated as a diagnostic and management tool for glaucoma.

Diagnosis and Management

A comprehensive ophthalmologic exam is required for the diagnosis of glaucoma, but no single test is adequate to establish diagnosis. A comprehensive ophthalmologic examination includes assessment of the optic nerve, evaluation of visual fields, and measurement of ocular pressure. The presence of characteristic changes in the optic nerve or abnormalities in visual field, together with increased intraocular pressure (IOP), is sufficient for a definitive diagnosis. However, some patients will show ophthalmologic evidence of glaucoma with normal IOPs. These cases of normal tension glaucoma are considered to be a type of primary open-angle glaucoma. Angle-closure glaucoma is another type of glaucoma associated with an increase in IOP. The increased IOP in angle-closure glaucoma arises from a reduction in aqueous outflow from the eye due to a closed angle in the anterior chamber. Diagnosis of angle-closure glaucoma is detailed in MP 311 Optical Coherence Tomography of the Anterior Eye Segment.

Conventional management of patients with glaucoma principally involves drug therapy to control elevated IOPs, and serial evaluation of the optic nerve, to follow disease progression. Standard methods of evaluation include careful direct examination of the optic nerve using ophthalmoscopy or stereophotography, or evaluation of visual fields. There is interest in developing more objective, reproducible techniques both to document optic nerve damage and to detect early changes in the optic nerve and retinal nerve fiber layer (RNFL) before the development of permanent visual field deficits. Specifically, evaluating changes in RNFL thickness has been investigated as a technique to diagnose and monitor glaucoma. However, IOP reduction is not effective in decreasing disease progression in a significant number of patients, and in patients with normal tension glaucoma, there is never an increase in IOP. It has been proposed that vascular dysregulation is a significant cause of damage to the RNFL, and there is interest in measuring ocular blood flow as both a diagnostic and a management tool for glaucoma. Changes in blood flow to the retina and choroid may be particularly relevant for diagnosis and treatment of normal tension glaucoma. A variety of techniques have been developed, as described below. (Note: This evidence review only addresses techniques related to the evaluation of the optic nerve, RNFL, or blood flow to the retina and choroid in patients with glaucoma.)

Techniques to Evaluate the Optic Nerve and Retinal Nerve Fiber Layer

Confocal Scanning Laser Ophthalmoscopy

Confocal scanning laser ophthalmoscopy (CSLO) is an image acquisition technique intended to improve the quality of the eye examination compared with standard ophthalmologic examination. A laser is scanned across the retina along with a detector system. Only a single spot on the retina is illuminated at any time, resulting in a high-contrast image of great reproducibility that can be used to estimate RNFL thickness. In addition, this technique does not require maximal mydriasis, which may be problematic in patients with glaucoma. The Heidelberg Retinal Tomograph is a commonly used technology.

Scanning Laser Polarimetry

The RNFL is birefringent (or biorefractive), meaning that it causes a change in the state of polarization of a laser beam as it passes. A 780-nm diode laser is used to illuminate the optic nerve. The polarization state of the light emerging from the eye is then evaluated and correlated with RNFL thickness. Unlike CSLO, scanning laser polarimetry (SLP) can directly measure the thickness of the RNFL. GDx is a common SLP device. GDx contains a normative database and statistical software package that compare scan results with age-matched normal subjects of the same ethnic origin. The advantages of this system are that images can be obtained without pupil dilation and evaluation can be completed in 10 minutes. Current instruments have added enhanced and variable corneal compensation technology to account for corneal polarization.

Optical Coherence Tomography

Optical coherence tomography (OCT) uses near-infrared light to provide direct cross-sectional measurement of the RNFL. The principles employed are similar to those used in B-mode ultrasound except light, not sound, is used to produce the 2-dimensional images. The light source can be directed into the eye through a conventional slit-lamp biomicroscope and focused onto the retina through a typical 78-diopter lens. This system requires dilation of the patient’s pupil. OCT analysis software is being developed to include optic nerve head parameters with spectral domain OCT, analysis of macular parameters, and hemodynamic parameters with Doppler OCT and OCT angiography.

Pulsatile Ocular Blood Flow

The pulsatile variation in ocular pressure results from the flow of blood into the eye during cardiac systole. Pulsatile ocular blood flow can thus be detected by the continuous monitoring of intraocular pressure. The detected pressure pulse can then be converted into a volume measurement using the known relationship between ocular pressure and ocular volume. Pulsatile blood flow is primarily determined by the choroidal vessels, particularly relevant to patients with glaucoma, since the optic nerve is supplied in large part by the choroidal circulation.

Techniques to Measure Ocular Blood Flow

A number of techniques have been developed to assess ocular blood flow. They include laser speckle flowgraphy, color Doppler imaging, Doppler Fourier domain OCT, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, and retinal functional imaging.

Laser Speckle Flowgraphy

Laser speckle is detected when a coherent light source such as laser light is dispersed from a diffusing surface such as retinal and choroidal vessels and the circulation of the optic nerve head. The varying patterns of light can be used to determine red blood cell velocity and retinal blood flow. However, due to differences in the tissue structure in different eyes, flux values cannot be used for comparisons between eyes. This limitation may be overcome by subtracting background choroidal blood flow results from the overall blood flow results in the region of interest.

Color Doppler Imaging

Color Doppler imaging has also been investigated as a technique to measure the blood velocity in the retinal and choroidal arteries. This technique delivers ultrasound in pulsed Doppler mode with a transducer set on closed eyelids. The examination takes 30 to 40 minutes, and is most effective for the mean velocity of large ophthalmic vessels such as the ophthalmic artery, the central retinal artery, and the short posterior ciliary arteries. However, total blood flow cannot be determined with this technique, and imaging is highly dependent on probe placement.

Doppler Fourier Domain OCT

Doppler Fourier domain OCT is a noncontact imaging technique that detects the intensity of the light scattered back from erythrocytes as they move in the vessels of the ocular tissue. This induces a frequency shift that represents the velocity of the blood in the ocular tissue.

Laser Doppler Velocimetry

Laser Doppler velocimetry compares the frequency of reflected laser light from a moving particle to stationary tissue.

Confocal Scanning Laser Doppler Flowmetry

Confocal scanning laser Doppler flowmetry combines laser Doppler flowmetry with confocal scanning laser tomography. Infrared laser light is used to scan the retina, and the frequency and amplitude of Doppler shifts are determined from the reflected light. Determinations of blood velocity and blood volume are used to compute the total blood flow and create a physical map of retinal flow values.

KEY POINTS:

The most recent literature search was performed through January 9, 2020.

SUMMARY OF EVIDENCE

For individuals who have glaucoma or suspected glaucoma who receive imaging of the optic nerve and RNFL, the evidence includes studies on diagnostic accuracy. Relevant outcomes are test accuracy, symptoms, morbid events, functional outcomes, and medication use. CSLO, SLP, and OCT can be used to evaluate the optic nerve and RNFL in patients with glaucoma and suspected glaucoma. Numerous articles have described findings from patients with known and suspected glaucoma using CSLO, SLP, and OCT. These studies have reported that abnormalities may be detected on these examinations before functional changes are noted. The literature and specialty society guidelines have indicated that optic nerve analysis using CSLO, SLP, and OCT are established add-on tests that may be used to diagnose and manage patients with glaucoma and suspected glaucoma. These results are often considered along with other findings to make diagnostic and therapeutic decisions about glaucoma care, including use of topical medication, monitoring, and surgery to lower IOP. Thus, accurate diagnosis of glaucoma would be expected to reduce the progression of glaucoma. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have glaucoma or suspected glaucoma who receive evaluation of ocular blood flow, the evidence includes association studies. Relevant outcomes are test accuracy, symptoms, morbid events, functional outcomes, and medication use. Techniques to measure ocular blood flow or ocular blood velocity are used to determine appropriate glaucoma treatment options. The data for these techniques remain limited. Literature reviews have not identified studies addressing whether these technologies improve diagnostic accuracy or whether they improve health outcomes in patients with glaucoma. Some have suggested that these parameters may inform understanding of the variability in visual field changes in patients with glaucoma, i.e., they may help explain why patients with similar levels of IOP develop markedly different visual impairments. However, data on use of ocular blood flow, pulsatile ocular blood flow, and/or blood flow velocity are currently lacking. The evidence is insufficient to determine the effects of the technology on health outcomes.

PRACTICE GUIDELINES AND POSITION STATEMENTS

American Academy of Ophthalmology

The American Academy of Ophthalmology issued 2 preferred practice patterns (2015) on primary open-angle glaucoma suspect and primary open-angle glaucoma, both recommending evaluation of the optic nerve and retinal nerve fiber layer (RNFL). The documents stated that “Although they are distinctly different methodologies, stereoscopic disc photographs and computerized images of the nerve are complementary with regard to the information they provide the clinician who must manage the patient.” The guidelines described 3 types of computer-based imaging devices (confocal scanning laser ophthalmoscopy, scanning laser polarimetry, optical coherence tomography) currently available for glaucoma, which are similar in their ability to distinguish glaucoma from controls and noted that “computer-based digital imaging of the ONH [optic nerve head] and RNFL is routinely used to provide quantitative information to supplement the clinical examination of the optic nerve…. One rationale for using computerized imaging is to distinguish glaucomatous damage from eyes without glaucoma when thinning of the RNFL is measured, thereby facilitating earlier diagnosis and detection of optic nerve damage”. In addition, the Academy concluded that, as device technology evolves, the performance of diagnostic imaging devices is expected to improve.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Doppler ultrasonography, glaucoma, GDx, Glaucoma scope, Heidelberg Retinal Tomograph, Nerve Fiber Analyzer, Ophthalmologic Evaluation, Glaucoma, Optic Nerve Head Analyzer, Optical Coherence Tomography, Pulsatile Ocular Blood Flow, Retinal Nerve Fiber Layer Analysis, Scanning Laser Ophthalmoscope, Scanning Laser Polarimetry, TopSS Device, RTVue® XR OCT Avanti™, The iExaminer™

APPROVED BY GOVERNING BODIES:

A number of CSLO, SLP, and OCT devices have been cleared by the FDA through the 510(k) process for imaging the posterior eye segment. For example, the RTVue® XR OCT Avanti™ is an OCT system indicated for the in vivo imaging and measurement of the retina, retinal nerve fiber layer, and optic disc as a tool and aid in the diagnosis and management of retinal diseases by a clinician. The RTVue XR OCT Avanti with Normative Database is a quantitative tool for the comparison of retina, retinal nerve fiber layer, and optic disk measurements in the human eye to a database of known normal subjects. It is intended for use as a diagnostic device to aid in the detection and management of ocular diseases. In 2016, the RTVue XR OCT with Avanti with AngioVue™ Software was cleared by the FDA through the 510(k) process (K153080) as an aid in the visualization of vascular structures of the retina and choroid.

In 2012, the iExaminer™ (Welch Allyn) was cleared for marketing by FDA through the 510(k) process. The iExaminer™ consists of a hardware adapter and associated software (iPhone® App) to capture, store, send, and retrieve images from the PanOptic™ Ophthalmoscope (Welch Allyn) using an iPhone.

Table 3. Ocular Imaging Devices Cleared by the US Food and Drug Administration

Device

Manufacturer

Date Cleared

510.k No.

Indication

RESCAN 700 CALLISTO eye

Carl Zeiss Meditec AG

1/11/2019

K180229

Imaging of optic nerve and retinal nerve fiber layer

Retina Workplace

Carl Zeiss Meditec Inc

10/24/2018

K182318

Imaging of optic nerve and retinal nerve fiber layer

Spectralis HRA+OCT and variants with High Magnification Module

Heidelberg Engineering GmbH

10/18/2018

K182569

Imaging of optic nerve and retinal nerve fiber layer

Spectralis HRA+OCT and variants with OCT Angiography Module

Heidelberg Engineering GmbH

9/13/2018

K181594

Imaging of optic nerve and retinal nerve fiber layer

Spectralis HRA + OCT and variants

Heidelberg Engineering GmbH

8/30/2018

K173648

Imaging of optic nerve and retinal nerve fiber layer

Image Filing Software NAVIS-EX

Nidek Co. Ltd

7/19/2018

K181345

Imaging of optic nerve and retinal nerve fiber layer

Avanti

Optovue Inc.

6/8/2018

K180660

Imaging of optic nerve and retinal nerve fiber layer

P200TE

Optos plc

2/28/2018

K173707

Imaging of optic nerve and retinal nerve fiber layer

DRI OCT Triton

Topcon Corporation

1/19/2018

K173119

Imaging of optic nerve and retinal nerve fiber layer

IMAGEnet 6 Ophthalmic Data System

Topcon Corporation

11/1/2017

K171370

Imaging of optic nerve and retinal nerve fiber layer

Spectralis HRA + OCT and variants Spectralis FA+OCT Spectralis ICGA+OCT Spectralis OCT Blue Peak Spectralis OCT with Multicolor

Heidelberg Engineering GmbH

11/1/2017

K172649

Imaging of optic nerve and retinal nerve fiber layer

PRIMUS

Carl Zeiss Suzhou Co. Ltd.

6/21/2017

K163195

Imaging of optic nerve and retinal nerve fiber layer

Retina Workplace

Carl Zeiss Meditec AG

6/21/2017

K170638

Imaging of optic nerve and retinal nerve fiber layer

iVue

Optovue Inc.

6/9/2017

K163475

Imaging of optic nerve and retinal nerve fiber layer

3D OCT-1 Maestro

Topcon Corporation

3/3/2017

K170164

Imaging of optic nerve and retinal nerve fiber layer

EnFocus 2300 EnFocus 4400

Bioptigen Inc.

12/9/2016

K162783

Imaging of optic nerve and retinal nerve fiber layer

PLEX Elite 9000 SS-OCT

CARL ZEISS MEDITEC INC.

10/26/2016

K161194

Imaging of optic nerve and retinal nerve fiber layer

3D OCT-1 Maestro

Topcon Corporation

7/28/2016

K161509

Imaging of optic nerve and retinal nerve fiber layer

LSFG-NAVI

Softcare Co. Ltd

5/12/2016

K153239

Imaging of optic nerve and retinal nerve fiber layer

Spectralis HRA + OCT and variants (e.g.s below) Spectralis FA+OCT Spectralis ICGA+OCT Spectralis OCT Blue Peak Spectralis OCT with Multicolor

Heidelberg Engineering GmbH

5/6/2016

K152205

Imaging of optic nerve and retinal nerve fiber layer

RTVue XR OCT Avanti with AngioVue Software

OPTOVUE INC.

2/11/2016

K153080

Imaging of optic nerve and retinal nerve fiber layer

EnFocus 2300 EnFocus 4400

BIOPTIGEN INC.

12/2/2015

K150722

Imaging of optic nerve and retinal nerve fiber layer

Optical Coherence Tomography

CARL ZEISS MEDITEC INC

9/1/2015

K150977

Imaging of optic nerve and retinal nerve fiber layer

OCT-Camera

OptoMedical Technologies GmbH

3/4/2015

K142953

Imaging of optic nerve and retinal nerve fiber layer

RESCAN 700 CALLISTO EYE

CARL ZEISS MEDITEC AG

11/18/2014

K141844

Imaging of optic nerve and retinal nerve fiber layer

PROPPER INSIGHT BINOCULAR INDIRECT OPHTHALMOSOPE

PROPPER MANUFACTURING CO.INC.

9/17/2014

K141638

Imaging of optic nerve and retinal nerve fiber layer

CENTERVUE MACULAR INTEGRITY ASSESSMENT

CENTERVUE SPA

4/23/2014

K133758

Imaging of optic nerve and retinal nerve fiber layer

AMICO DH-W35 OPHTHALMOSCOPE SERIES

AMICO DIAGNOSTIC INCORPORATED

3/26/2014

K131939

Imaging of optic nerve and retinal nerve fiber layer

IVUE 500

OPTOVUE INC.

3/19/2014

K133892

Imaging of optic nerve and retinal nerve fiber layer

RS-3000 ADVANCE

NIDEK CO. LTD.

2/19/2014

K132323

Imaging of optic nerve and retinal nerve fiber layer

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING:

CPT Codes:

92133

Scanning computerized ophthalmic diagnostic imaging, posterior segment; with interpretation and report, unilateral or bilateral; optic nerve

0198T

Measurement of ocular blood flow by repetitive pressure sampling, with interpretation and report

REFERENCES:

  1. Abegao Pinto L, Willekens K, Van Keer K, et al. Ocular blood flow in glaucoma - the Leuven Eye Study. Acta Ophthalmol. Sep 2016; 94(6):592-598.
  2. American Academy of Ophthalmology. Preferred Practice Pattern: Primary open-angle suspect. 2015; //www.aaojournal.org/article/S0161-6420 (15)01278-6/pdf. Accessed February 26, 2018.
  3. American Academy of Ophthalmology. Preferred Practice Pattern: Primary open-angle glaucoma. 2015; //www.aaojournal.org/article/S0161-6420 (15)01276-2/pdf. Accessed February 26, 2018.
  4. The American Optometric Association. Care of the Patient with Open Angle Glaucoma. 2010; my.ico.edu/file/CPG-9---Open-Angel-Glaucoma.pdf.
  5. American Academy of Ophthalmology. Primary open-angle glaucoma suspect. Preferred practice pattern. San Francisco: American Academy of Ophthalmology. 2010. Available online at: one.aao.org/CE/PracticeGuidelines/default.aspx?dc=1902a3e2-bc8f-4a97-b200-97a4c7682b50&sid=ca9ec1b5-2567-4e85-96f6-b6540e5ac5a1.
  6. American Academy of Ophthalmology. Primary open-angle glaucoma. Preferred practice pattern. San Francisco: American Academy of Ophthalmology. 2010. Available online at: one.aao.org/CE/PracticeGuidelines/default.aspx?dc=1902a3e2-bc8f-4a97-b200-97a4c7682b50&sid=ca9ec1b5-2567-4e85-96f6-b6540e5ac5a1.
  7. Bafa M, Lambrinakis I, Dayan M et al. Clinical comparison of the measurement of the IOP with the ocular blood flow tonometer, the Tonopen XL and the Goldmann applanation tonometer. Acta Ophthalmol Scand 2001; 79(1):15-8.
  8. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Retinal nerve fiber analysis for the diagnosis and management of glaucoma. TEC Assessments 2001; Volume 16, Tab 13.
  9. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Retinal nerve fiber layer analysis for the diagnosis and management of glaucoma. TEC Assessments 2003; Volume 18, Tab 7.
  10. Calvo P, Ferreras A, Polo V et al. Predictive value of retrobulbar blood flow velocities in glaucoma suspects. Invest Ophthalmol Vis Sci 2012; 53(7):3875-84.
  11. Chauhan BC, Hicolela MT, Artes PH. Incidence and rates of visual field progression after longitudinally measured optic disc change in glaucoma. Ophthalmology 2009: 116(11):2110-8.
  12. Cioffi GA. Three assumptions: ocular blood flow and glaucoma. J Glaucoma 1998; 7(5):299-300.
  13. Ervin AM, Boland MV, Myrowitz EH et al. Screening for Glaucoma: Comparative Effectiveness. Comparative Effectiveness Review No. 59 (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-2007-10061.) AHRQ Publication No. 12-EHC037-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012. Available online at: www.effectivehealthcare.ahrq.gov/ehc/products/182/1026/CER59_Glaucoma- Screening_Final-Report_20120524.pdf.
  14. Fontana L, Poinoosawmy D, Bunce CV et al. Pulsatile ocular blood flow investigation in asymmetric normal tension glaucoma and normal subjects. Br J Ophthalmol 1998; 82(7):731-6.
  15. Grewal DS, Sehi M, Greenfield DS, et al. Comparing rates of retinal nerve fibre layer loss with GDxECC using different methods of visual-field progression. Br J Ophthalmol 2011; 95(8):1122-1127.
  16. Harris A, Kagermann L, Ehrlich R et al. Measuring and interpreting ocular blood flow and metabolism in glaucoma. Can J Ophthalmol 2008; 43(3):328-36.
  17. James CB. Pulsatile ocular blood flow. Br J Ophthalmol 1998; 82(7):720-1.
  18. Kaiser HJ, Schoetzau A, Stumpfig D et al. Blood-flow velocities of the extraocular vessels in patients with high-tension and normal-tension primary open-angle glaucoma. Am J Ophthalmol 1997; 123(3):320-7.
  19. Kalaboukhova L, Fridhammar V, Lindblom B. Glaucoma follow-up by the Heidelberg Retina Tomograph. Graefes Arch Clin Exp Ophthalmol 2006 Jun; 244(6):654-62.
  20. Kamal DS, Garway-Heath DF, Hitchings RA et al. Use of sequential Heidelberg retina tomograph images to identify changes at the optic disc in ocular hypertensive patients at risk of developing glaucoma. Br J Ophthalmol 2000; 84(9):993-8.
  21. Kurysheva NI, Parshunina OA, Shatalova EO, et al. Value of structural and hemodynamic parameters for the early detection of primary open-angle glaucoma. Curr Eye Res. Mar 2017; 42(3):411-417.
  22. Kwartz AJ, Henson DB, Harper RA et al. The effectiveness of the Heidelberg Retina Tomograph and laser diagnostic glaucoma scanning system (GDx) in detecting and monitoring glaucoma. Health Technol Assess 2005; 9(46):1-132, iii.
  23. Lalezary M, Medeiros FA, Weinreb RN et al. Baseline optical coherence tomography predicts the development of glaucomatous change in glaucoma suspects. Am J Ophthalmol 2006; 142(4):576-82.
  24. Lin SC, Singh K, Jampel HD et al. Optic nerve head and retinal nerve fiber layer analysis: a report by the American Academy of Ophthalmology. Ophthalmology 2007; 114(10):1937-49.
  25. Medeiros FA, Ng D, Zangwill LM et al. The effects of study design and spectrum bias on the evaluation of diagnostic accuracy of confocal scanning laser ophthalmoscopy in glaucoma. Invest Ophthalmol Vis Sci 2007; 48(1):214-22.
  26. Michelessi M, Lucenteforte E, Oddone F, et al. Optic nerve head and fiber layer imaging for diagnosing glaucoma. Cochrane Database Syst Rev. 2015(11):CD008803.
  27. Mohammadi K, Bowd C, Weinreb RN et al. Retinal nerve fiber layer thickness measurements with scanning laser polarimetry predicts glaucomatous visual field loss. Am J Ophthalmol 2004; 138(4):592-601.
  28. Mohindroo C, Ichhpujani P, Kumar S. Current imaging modalities for assessing ocular blood flow in glaucoma. J Curr Glaucoma Pract. Sep-Dec 2016; 10(3):104-112.
  29. Rankin SJ, Walman BE, Buckley AR et al. Color Doppler imaging and spectral analysis of the optic nerve vasculature in glaucoma. Am J Ophthalmol 1995; 119(6):685-93.
  30. Resch H, Schmidl D, Hommer A et al. Correlation of optic disc morphology and ocular perfusion parameters in patients with primary open angle glaucoma. Acta Ophthalmol 2011; 89(7):e544-9.
  31. Rusia D, Harris A, Pernic A et al. Feasibility of creating a normative database of colour Doppler imaging parameters in glaucomatous eyes and controls. Br J Ophthalmol 2011; 95(9):1193-1198.
  32. Schmidl D, Garhofer G, Schmetterer L. The complex interaction between ocular perfusion pressure and ocular blood flow – Relevance for glaucoma. Exp Eye Res 2011; 93(2):141-155.
  33. Shiga Y, Omodaka K, Kunikata H et al. Waveform analysis of ocular blood flow and the early detection of normal tension glaucoma. Invest Ophthalmol Vis Sci 2013; 54(12):7699-706.
  34. Witkowska KJ, Bata AM, Calzetti G, et al. Optic nerve head and retinal blood flow regulation during isometric exercise as assessed with laser speckle flowgraphy. PLoS One. Sep 12 2017; 12(9):e0184772.
  35. Zangwill LM, Weinreb RN, Beiser JA et al. Baseline topographic optic disc measurements are associated with the development of primary open-angle glaucoma: the confocal scanning laser ophthalmoscopy ancillary study to the ocular hypertension treatment study. Arch Ophthalmol 2005; 123(9):1188-97.
  36. Zangwill LM, Weinreb RN, Berry CC et al. The confocal scanning laser ophthalmoscopy ancillary study to the ocular hypertension treatment study: study design and baseline factors. Am J Ophthalmol 2004; 137(2):219-27.

POLICY HISTORY:

Medical Policy Group, February 2011 (2)

Medical Policy Administration Committee, February 2011

Available for comment February 9 – March 25, 2011

Medical Policy Group, February 2012 (3): Assoc 2012 Update to Description, Key Points, References

Medical Policy Panel, February 2013

Medical Policy Group, February 2013 (3): Update to Key Points, Approved by Governing Bodies and References; no change to policy statement

Medical Policy Panel, February 2014

Medical Policy Group, February 2014 (1): Update to Key Points and References; no change to policy statement

Medical Policy Panel, February 2015

Medical Policy Group, February 2015 (6):  Update to Key Points and References; no change to policy statement

Medical Policy Panel, August 2016

Medical Policy Group, September 2016 (6): Updates to Description, Key Points, Regulatory Status, Practice Guidelines, Summary and References. No change to policy intent.

Medical Policy Panel, March 2017

Medical Policy Group, April 2017 (6): Updates to Description, Key Points and References.

Medical Policy Panel, March 2018

Medical Policy Group, March 2018 (6): Updates to Description, Key Points, Key Words and References.

Medical Policy Panel, March 2019

Medical Policy Group, April 2019 (6): Updates to Key Points and Approved by Governing Bodies, Title changed to “Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma”. No change in policy statement.

Medical Policy Panel, March 2020

Medical Policy Group, March 2020 (6): Updates to Key Points.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.