Local Coverage Determination (LCD): Visual Electrophysiology Testing (L36831)

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Document Information

LCD ID Original Effective Date

Printed on 8/29/2017. Page 1 of 16 L36831 For services performed on or after 03/16/2017

LCD Title Revision Effective Date Visual Electrophysiology Testing For services performed on or after 03/16/2017

Proposed LCD in Comment Period Revision Ending Date N/A N/A

Source Proposed LCD Retirement Date DL36831 N/A

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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 the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician

Printed on 8/29/2017. Page 2 of 16 provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

Abstract

VEP/VER - The visual evoked response (VER) and visual evoked potential (VEP) evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain. By measuring the function of the entire visual pathway, it helps to separate from central nervous system defects. VER/VEP involves stimulation of the and with a shifting checkerboard pattern or flash method. This external visual stimulus causes measurable electrical activity in neurons within the visual pathways. The VER is recorded by electroencephalography electrodes located over the occiput producing a characteristic waveform. Abnormalities may be seen in a variety of pathologic processes involving the optic nerve and its radiations. Pattern-shift VER is a highly sensitive means of documenting lesions in the .

ERG - The full field electroretinogram (ERG) is used to detect loss of retinal function or distinguish between retinal and optic nerve lesions. ERG measures the electrical activity generated by neural and non-neuronal cells in the retina in response to a light stimulus. ERGs are usually obtained using electrodes embedded in a corneal contact , or a thin wire inside the lower , which measure a summation of retinal electrical activity at the corneal surface. The International Society for Clinical Electrophysiology of Vision (ISCEV) introduced minimum standards for the ERG in 1989. The ERG helps to distinguish retinal degeneration and dystrophies. Multi-focal electroretinography (mfERG) is a higher resolution form of ERG, enabling assessment of ERG activity in small areas of the retina. Pattern ERG (PERG) to assess retinal ganglion cell (RGC) function in is being investigated.

Indications of Coverage

Visual Evoked Potentials or Responses (VEPs/VERs)

1. Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive 2. Evaluate diseases of the optic nerve, such as: a. b. Ischemic c. Toxic amblyopias d. Nutritional amblyopias e. Neoplasms compressing the anterior visual pathways f. Optic nerve injury or atrophy g. Malingering/functional vision loss (to rule out) 3. Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

Electroretinography (ERG)

1. To diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions:

Printed on 8/29/2017. Page 3 of 16 a. Toxic , including those caused by intraocular metallic foreign bodies and Vigabatrin b. Diabetic c. Ischemic retinopathies including central retinal vein occlusion (CRVO), branch vein occlusion (BVO), and d. Autoimmune retinopathies such as Cancer Associated Retinopathy (CAR), Melanoma Associated Retinopathy (MAR), and Acute Zonal Occult Outer Retinopathy (AZOOR) e. f. Assessment of retinal function after trauma, especially in vitreous hemorrhage, dense , and other conditions where the fundus cannot be visualized photoreceptors; absent b-wave indicates abnormality in the bipolar cell region. g. pigmentosa and related hereditary degenerations h. Retinitis punctata albescens i. Leber's congenital amaurosis j. k. Gyrate atrophy of the retina and l. Goldman-Favre syndrome m. Congenital stationary night blindness n. X-linked juvenile o. p. Cone dystrophy q. Disorders mimicking r. Usher Syndrome 2. To detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity (mfERG) per AAO guidelines (10).

VEP/ERG in Glaucoma

A 2011 report by the AAO on “Assessment of Visual Function in Glaucoma” noted that while VEP and ERG, as objective measures of visual function, provided testing free of patient input, issues prevent their adoption for glaucoma management (1). It concluded that advances in technology have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time and that further research on an objective measure of visual function is needed.

Since then several studies (2-5) have investigated the use of VEP and ERG technology to differentiate between normal healthy eyes and eyes with early to advanced visual field loss resulting from glaucoma. The authors indicated that VEP and ERG may allow earlier diagnosis of glaucoma. However, NGS has determined that without larger studies, AAO’s 2011 conclusion, that these technologies have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time, remains. This was also the conclusion of a 2013 study which prospectively monitored progressive changes of RGC function in early glaucoma using PERG (6). The authors concluded that further follow-up is required to determine whether PERG losses are predictors of future visual field loss.

Neither of the 2015 AAO Preferred Practice Guidelines, “Primary Open-Angle Glaucoma Suspect” or “Primary Open-Angle Glaucoma,” mention VEP or ERG as diagnostic tools (7,8). Also, the UpToDate review on “Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis,” likewise omits reference to either test (9).

There remain no verified guidelines for normal vs abnormal that would be easily applicable to an individual patient. NGS, therefore, considers the use of VEP or ERG for either glaucoma diagnosis or management investigational.

Limitations

Testing shall be performed by physicians who have evidence of knowledge, training, and expertise to perform and interpret these tests. This training and expertise must have been acquired within the framework of an accredited school, residency or fellowship program.

Summary of Evidence

N/A

Printed on 8/29/2017. Page 4 of 16 Analysis of Evidence (Rationale for Determination)

N/A

Back to Top Coding Information

Bill Type Codes:

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.

N/A Revenue Codes:

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 CPT/HCPCS Codes Group 1 Paragraph: N/A

Group 1 Codes: 92275 ELECTRORETINOGRAPHY WITH INTERPRETATION AND REPORT 95930 VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS SYSTEM, CHECKERBOARD OR FLASH

Group 2 Paragraph:

The CPT codes listed below are considered not medically necessary:

Group 2 Codes: 0333T VISUAL EVOKED POTENTIAL, SCREENING OF VISUAL ACUITY, AUTOMATED, WITH REPORT 0464T VISUAL EVOKED POTENTIAL, TESTING FOR GLAUCOMA, WITH INTERPRETATION AND REPORT

ICD-10 Codes that Support Medical Necessity Group 1 Paragraph:

The ICD-10-CM diagnosis codes in Group 1 below support the medical necessity of CPT code 95930 only.

Group 1 Codes: ICD-10 Codes Description G35 Multiple sclerosis G36.0 Neuromyelitis optica [Devic] G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]

Printed on 8/29/2017. Page 5 of 16 ICD-10 Codes Description G36.8 Other specified acute disseminated demyelination H46.01 - H46.03 , right eye - Optic papillitis, bilateral H46.11 - H46.13 Retrobulbar neuritis, right eye - Retrobulbar neuritis, bilateral H46.2 - H46.9 Nutritional optic neuropathy - Unspecified optic neuritis H47.011 - Ischemic optic neuropathy, right eye - Ischemic optic neuropathy, bilateral H47.013 H47.021 - Hemorrhage in optic nerve sheath, right eye - Hemorrhage in optic nerve sheath, bilateral H47.023 H47.031 - Optic nerve hypoplasia, right eye - Optic nerve hypoplasia, bilateral H47.033 H47.091 - Other disorders of optic nerve, not elsewhere classified, right eye - Other disorders of optic H47.093 nerve, not elsewhere classified, bilateral H47.10 - H47.13 Unspecified - Papilledema associated with retinal disorder H47.141 - Foster-Kennedy syndrome, right eye - Foster-Kennedy syndrome, bilateral H47.143 H47.20 - H47.213 Unspecified optic atrophy - Primary optic atrophy, bilateral H47.22 - H47.233 Hereditary optic atrophy - Glaucomatous optic atrophy, bilateral H47.291 - Other optic atrophy, right eye - Other optic atrophy, bilateral H47.293 H47.311 - of , right eye - Coloboma of optic disc, bilateral H47.313 H47.321 - Drusen of optic disc, right eye - Drusen of optic disc, bilateral H47.323 H47.331 - Pseudopapilledema of optic disc, right eye - Pseudopapilledema of optic disc, bilateral H47.333 H47.391 - Other disorders of optic disc, right eye - Other disorders of optic disc, bilateral H47.393 Disorders of optic chiasm in (due to) inflammatory disorders - Disorders of optic chiasm in H47.41 - H47.49 (due to) other disorders H47.521 Disorders of visual pathways in (due to) neoplasm, right side H47.522 Disorders of visual pathways in (due to) neoplasm, left side H53.011 - Deprivation , right eye - Deprivation amblyopia, bilateral H53.013 H53.021 - Refractive amblyopia, right eye - Refractive amblyopia, bilateral H53.023 H53.031 - Strabismic amblyopia, right eye - Strabismic amblyopia, bilateral H53.033 H54.0 Blindness, both eyes H54.11 - H54.12 Blindness, right eye, low vision left eye - Blindness, left eye, low vision right eye H54.2 - H54.3 Low vision, both eyes - Unqualified visual loss, both eyes H54.41 - H54.42 Blindness, right eye, normal vision left eye - Blindness, left eye, normal vision right eye H54.51 - H54.52 Low vision, right eye, normal vision left eye - Low vision, left eye, normal vision right eye Unqualified visual loss, right eye, normal vision left eye - Unqualified visual loss, left eye, H54.61 - H54.62 normal vision right eye H54.7 - H54.8 Unspecified visual loss - Legal blindness, as defined in USA S04.011A - Injury of optic nerve, right eye, initial encounter - Injury of visual cortex, left eye, sequela S04.042S

Group 2 Paragraph:

The ICD-10-CM diagnosis codes in Group 2 below support the medical necessity of CPT code 92275 only.

Group 2 Codes: ICD-10 Description Codes A18.53 Tuberculous B50.0 Plasmodium falciparum malaria with cerebral complications B50.8 Other severe and complicated Plasmodium falciparum malaria Printed on 8/29/2017. Page 6 of 16 ICD-10 Description Codes B50.9 Plasmodium falciparum malaria, unspecified D18.09 Hemangioma of other sites Diabetes mellitus due to underlying condition with unspecified with macular E08.311 - edema - Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without E08.319 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E08.3211 - macular edema, right eye - Diabetes mellitus due to underlying condition with mild nonproliferative E08.3213 diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E08.3291 - macular edema, right eye - Diabetes mellitus due to underlying condition with mild nonproliferative E08.3293 diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3311 - with macular edema, right eye - Diabetes mellitus due to underlying condition with moderate E08.3313 nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3391 - without macular edema, right eye - Diabetes mellitus due to underlying condition with moderate E08.3393 nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E08.3411 - macular edema, right eye - Diabetes mellitus due to underlying condition with severe E08.3413 nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy E08.3491 - without macular edema, right eye - Diabetes mellitus due to underlying condition with severe E08.3493 nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E08.3511 - edema, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic E08.3513 retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3521 - retinal detachment involving the macula, right eye - Diabetes mellitus due to underlying condition E08.3523 with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3531 - retinal detachment not involving the macula, right eye - Diabetes mellitus due to underlying E08.3533 condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E08.3541 - traction retinal detachment and rhegmatogenous retinal detachment, right eye - Diabetes mellitus E08.3543 due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E08.3551 - - Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, E08.3553 bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E08.3591 - edema, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic E08.3593 retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular E09.311 - edema - Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without E09.319 macular edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with E09.3211 - macular edema, right eye - Drug or chemical induced diabetes mellitus with mild nonproliferative E09.3213 diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E09.3291 - macular edema, right eye - Drug or chemical induced diabetes mellitus with mild nonproliferative E09.3293 diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E09.3311 - macular edema, right eye - Drug or chemical induced diabetes mellitus with moderate E09.3313 nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy E09.3391 - without macular edema, right eye - Drug or chemical induced diabetes mellitus with moderate E09.3393 nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E09.3411 - macular edema, right eye - Drug or chemical induced diabetes mellitus with severe nonproliferative E09.3413 diabetic retinopathy with macular edema, bilateral

Printed on 8/29/2017. Page 7 of 16 ICD-10 Description Codes E09.3491 - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E09.3493 macular edema, right eye - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular E09.3511 - edema, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy E09.3513 with macular edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3521 - retinal detachment involving the macula, right eye - Drug or chemical induced diabetes mellitus E09.3523 with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3531 - retinal detachment not involving the macula, right eye - Drug or chemical induced diabetes mellitus E09.3533 with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E09.3541 - traction retinal detachment and rhegmatogenous retinal detachment, right eye - Drug or chemical E09.3543 induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E09.3551 - Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye - E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E09.3591 - edema, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy E09.3593 without macular edema, bilateral E10.311 - Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 1 E10.319 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E10.3211 - eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E10.3213 bilateral Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E10.3291 - right eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E10.3293 edema, bilateral Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E10.3311 - right eye - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with E10.3313 macular edema, bilateral Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E10.3391 - edema, right eye - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy E10.3393 without macular edema, bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E10.3411 - eye - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E10.3413 edema, bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E10.3491 - right eye - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without E10.3493 macular edema, bilateral E10.3511 - Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E10.3521 - involving the macula, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with E10.3523 traction retinal detachment involving the macula, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E10.3531 - involving the macula, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with E10.3533 traction retinal detachment not involving the macula, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E10.3541 - detachment and rhegmatogenous retinal detachment, right eye - Type 1 diabetes mellitus with E10.3543 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 - Type 1 diabetes E10.3553 mellitus with stable proliferative diabetic retinopathy, bilateral E10.3591 - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right 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 - Type 2 E11.319 diabetes mellitus with unspecified diabetic retinopathy without macular edema

Printed on 8/29/2017. Page 8 of 16 ICD-10 Description Codes E11.3211 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E11.3213 eye - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E11.3291 - right eye - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E11.3293 edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E11.3311 - right eye - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with E11.3313 macular edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E11.3391 - edema, right eye - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy E11.3393 without macular edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E11.3411 - eye - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E11.3413 edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E11.3491 - right eye - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without E11.3493 macular edema, bilateral E11.3511 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E11.3521 - involving the macula, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with E11.3523 traction retinal detachment involving the macula, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E11.3531 - involving the macula, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with E11.3533 traction retinal detachment not involving the macula, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E11.3541 - detachment and rhegmatogenous retinal detachment, right eye - Type 2 diabetes mellitus with E11.3543 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 - Type 2 diabetes E11.3553 mellitus with stable proliferative diabetic retinopathy, bilateral E11.3591 - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye - E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E13.311 - Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema - Other E13.319 specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E13.3211 - edema, right eye - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy E13.3213 with macular edema, bilateral Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E13.3291 - edema, right eye - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy E13.3293 without macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E13.3311 - edema, right eye - Other specified diabetes mellitus with moderate nonproliferative diabetic E13.3313 retinopathy with macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without E13.3391 - macular edema, right eye - Other specified diabetes mellitus with moderate nonproliferative diabetic E13.3393 retinopathy without macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E13.3411 - edema, right eye - Other specified diabetes mellitus with severe nonproliferative diabetic E13.3413 retinopathy with macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E13.3491 - edema, right eye - Other specified diabetes mellitus with severe nonproliferative diabetic E13.3493 retinopathy without macular edema, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E13.3511 - eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, E13.3513 bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3521 - detachment involving the macula, right eye - Other specified diabetes mellitus with proliferative E13.3523 diabetic retinopathy with traction retinal detachment involving the macula, bilateral E13.3531 - E13.3533

Printed on 8/29/2017. Page 9 of 16 ICD-10 Description Codes Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction E13.3541 - retinal detachment and rhegmatogenous retinal detachment, right eye - Other specified diabetes E13.3543 mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E13.3551 - Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye - Other E13.3553 specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, E13.3591 - right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular E13.3593 edema, bilateral G45.3 Amaurosis fugax H30.001 - Unspecified focal chorioretinal inflammation, right eye - Unspecified focal chorioretinal inflammation, H30.003 bilateral H30.011 - Focal chorioretinal inflammation, juxtapapillary, right eye - Focal chorioretinal inflammation, H30.013 juxtapapillary, bilateral H30.021 - Focal chorioretinal inflammation of posterior pole, right eye - Focal chorioretinal inflammation of H30.023 posterior pole, bilateral H30.031 - Focal chorioretinal inflammation, peripheral, right eye - Focal chorioretinal inflammation, peripheral, H30.033 bilateral H30.041 - Focal chorioretinal inflammation, macular or paramacular, right eye - Focal chorioretinal H30.043 inflammation, macular or paramacular, bilateral H30.101 - Unspecified disseminated chorioretinal inflammation, right eye - Unspecified disseminated H30.103 chorioretinal inflammation, bilateral H30.111 - Disseminated chorioretinal inflammation of posterior pole, right eye - Disseminated chorioretinal H30.113 inflammation of posterior pole, bilateral H30.121 - Disseminated chorioretinal inflammation, peripheral right eye - Disseminated chorioretinal H30.123 inflammation, peripheral, bilateral H30.131 - Disseminated chorioretinal inflammation, generalized, right eye - Disseminated chorioretinal H30.133 inflammation, generalized, bilateral H30.141 - Acute posterior multifocal placoid pigment epitheliopathy, right eye - Acute posterior multifocal H30.143 placoid pigment epitheliopathy, bilateral H30.21 - Posterior cyclitis, right eye - Posterior cyclitis, bilateral H30.23 H30.811 - Harada's disease, right eye - Harada's disease, bilateral H30.813 H30.891 - Other chorioretinal inflammations, right eye - Other chorioretinal inflammations, bilateral H30.893 H30.91 - Unspecified chorioretinal inflammation, right eye - Unspecified chorioretinal inflammation, bilateral H30.93 H31.001 - Unspecified chorioretinal scars, right eye - Unspecified chorioretinal scars, bilateral H31.003 H31.011 - Macula scars of posterior pole (postinflammatory) (post-traumatic), right eye - Macula scars of H31.013 posterior pole (postinflammatory) (post-traumatic), bilateral H31.021 - Solar retinopathy, right eye - Solar retinopathy, bilateral H31.023 H31.091 - Other chorioretinal scars, right eye - Other chorioretinal scars, bilateral H31.093 H31.101 - Choroidal degeneration, unspecified, right eye - Choroidal degeneration, unspecified, bilateral H31.103 H31.111 - Age-related choroidal atrophy, right eye - Age-related choroidal atrophy, bilateral H31.113 H31.121 - Diffuse secondary atrophy of choroid, right eye - Diffuse secondary atrophy of choroid, bilateral H31.123 H31.20 Hereditary choroidal dystrophy, unspecified H31.21 Choroideremia H31.22 Choroidal dystrophy (central areolar) (generalized) (peripapillary) H31.23 Gyrate atrophy, choroid H31.29 Other hereditary choroidal dystrophy Unspecified choroidal hemorrhage, right eye - Unspecified choroidal hemorrhage, bilateral Printed on 8/29/2017. Page 10 of 16 ICD-10 Description Codes H31.301 - H31.303 H31.311 - Expulsive choroidal hemorrhage, right eye - Expulsive choroidal hemorrhage, bilateral H31.313 H31.321 - Choroidal rupture, right eye - Choroidal rupture, bilateral H31.323 H31.401 - Unspecified choroidal detachment, right eye - Unspecified choroidal detachment, bilateral H31.403 H31.411 - Hemorrhagic choroidal detachment, right eye - Hemorrhagic choroidal detachment, bilateral H31.413 H31.421 - Serous choroidal detachment, right eye - Serous choroidal detachment, bilateral H31.423 H33.001 - Unspecified retinal detachment with retinal break, right eye - Unspecified retinal detachment with H33.003 retinal break, bilateral H33.011 - Retinal detachment with single break, right eye - Retinal detachment with single break, bilateral H33.013 H33.021 - Retinal detachment with multiple breaks, right eye - Retinal detachment with multiple breaks, H33.023 bilateral H33.031 - Retinal detachment with giant retinal tear, right eye - Retinal detachment with giant retinal tear, H33.033 bilateral H33.041 - Retinal detachment with retinal dialysis, right eye - Retinal detachment with retinal dialysis, bilateral H33.043 H33.051 - Total retinal detachment, right eye - Total retinal detachment, bilateral H33.053 H33.101 - Unspecified retinoschisis, right eye - Unspecified retinoschisis, bilateral H33.103 H33.111 - Cyst of ora serrata, right eye - Cyst of ora serrata, bilateral H33.113 H33.191 - Other retinoschisis and retinal cysts, right eye - Other retinoschisis and retinal cysts, bilateral H33.193 H33.21 - Serous retinal detachment, right eye - Serous retinal detachment, bilateral H33.23 H33.301 - Unspecified retinal break, right eye - Unspecified retinal break, bilateral H33.303 H33.311 - Horseshoe tear of retina without detachment, right eye - Horseshoe tear of retina without H33.313 detachment, bilateral H33.321 - Round hole, right eye - Round hole, bilateral H33.323 H33.331 - Multiple defects of retina without detachment, right eye - Multiple defects of retina without H33.333 detachment, bilateral H33.41 - Traction detachment of retina, right eye - Traction detachment of retina, bilateral H33.43 H33.8 Other retinal detachments H34.01 - Transient retinal artery occlusion, right eye - Transient retinal artery occlusion, bilateral H34.03 H34.11 - Central retinal artery occlusion, right eye - Central retinal artery occlusion, bilateral H34.13 H34.211 - Partial retinal artery occlusion, right eye - Partial retinal artery occlusion, bilateral H34.213 H34.231 - Retinal artery branch occlusion, right eye - Retinal artery branch occlusion, bilateral H34.233 H34.8110 - Central retinal vein occlusion, right eye, with macular edema - Central retinal vein occlusion, right H34.8112 eye, stable H34.8120 - Central retinal vein occlusion, left eye, with macular edema - Central retinal vein occlusion, left eye, H34.8122 stable H34.8130 - Central retinal vein occlusion, bilateral, with macular edema - Central retinal vein occlusion, H34.8132 bilateral, stable H34.821 - Venous engorgement, right eye - Venous engorgement, bilateral H34.823 H34.8310 - Tributary (branch) retinal vein occlusion, right eye, with macular edema - Tributary (branch) retinal H34.8312 vein occlusion, right eye, stable

Printed on 8/29/2017. Page 11 of 16 ICD-10 Description Codes H34.8320 - Tributary (branch) retinal vein occlusion, left eye, with macular edema - Tributary (branch) retinal H34.8322 vein occlusion, left eye, stable H34.8330 - Tributary (branch) retinal vein occlusion, bilateral, with macular edema - Tributary (branch) retinal H34.8332 vein occlusion, bilateral, stable H34.9 Unspecified retinal vascular occlusion H35.00 Unspecified background retinopathy H35.011 - Changes in retinal vascular appearance, right eye - Changes in retinal vascular appearance, bilateral H35.013 H35.021 - Exudative retinopathy, right eye - Exudative retinopathy, bilateral H35.023 H35.031 - , right eye - Hypertensive retinopathy, bilateral H35.033 H35.041 - Retinal micro-aneurysms, unspecified, right eye - Retinal micro-aneurysms, unspecified, bilateral H35.043 H35.051 - Retinal neovascularization, unspecified, right eye - Retinal neovascularization, unspecified, bilateral H35.053 H35.061 - Retinal vasculitis, right eye - Retinal vasculitis, bilateral H35.063 H35.071 - Retinal telangiectasis, right eye - Retinal telangiectasis, bilateral H35.073 H35.09 Other intraretinal microvascular abnormalities H35.101 - Retinopathy of prematurity, unspecified, right eye - Retinopathy of prematurity, unspecified, H35.103 bilateral H35.111 - Retinopathy of prematurity, stage 0, right eye - Retinopathy of prematurity, stage 0, bilateral H35.113 H35.121 - Retinopathy of prematurity, stage 1, right eye - Retinopathy of prematurity, stage 1, bilateral H35.123 H35.131 - Retinopathy of prematurity, stage 2, right eye - Retinopathy of prematurity, stage 2, bilateral H35.133 H35.141 - Retinopathy of prematurity, stage 3, right eye - Retinopathy of prematurity, stage 3, bilateral H35.143 H35.151 - Retinopathy of prematurity, stage 4, right eye - Retinopathy of prematurity, stage 4, bilateral H35.153 H35.161 - Retinopathy of prematurity, stage 5, right eye - Retinopathy of prematurity, stage 5, bilateral H35.163 H35.171 - Retrolental fibroplasia, right eye - Retrolental fibroplasia, bilateral H35.173 H35.21 - Other non-diabetic proliferative retinopathy, right eye - Other non-diabetic proliferative retinopathy, H35.23 bilateral H35.30 Unspecified H35.3110 - Nonexudative age-related macular degeneration, right eye, stage unspecified - Nonexudative age- H35.3134 related macular degeneration, bilateral, advanced atrophic with subfoveal involvement H35.3210 - Exudative age-related macular degeneration, right eye, stage unspecified - Exudative age-related H35.3233 macular degeneration, bilateral, with inactive scar H35.33 Angioid streaks of macula H35.341 - Macular cyst, hole, or pseudohole, right eye - Macular cyst, hole, or pseudohole, bilateral H35.343 H35.351 - Cystoid macular degeneration, right eye - Cystoid macular degeneration, bilateral H35.353 H35.361 - Drusen (degenerative) of macula, right eye - Drusen (degenerative) of macula, bilateral H35.363 H35.371 - Puckering of macula, right eye - Puckering of macula, bilateral H35.373 H35.381 - Toxic maculopathy, right eye - Toxic maculopathy, bilateral H35.383 H35.40 Unspecified peripheral retinal degeneration H35.411 - Lattice degeneration of retina, right eye - Lattice degeneration of retina, bilateral H35.413 H35.421 - Microcystoid degeneration of retina, right eye - Microcystoid degeneration of retina, bilateral H35.423 Paving stone degeneration of retina, right eye - Paving stone degeneration of retina, bilateral Printed on 8/29/2017. Page 12 of 16 ICD-10 Description Codes H35.431 - H35.433 H35.441 - Age-related reticular degeneration of retina, right eye - Age-related reticular degeneration of retina, H35.443 bilateral H35.451 - Secondary pigmentary degeneration, right eye - Secondary pigmentary degeneration, bilateral H35.453 H35.461 - Secondary vitreoretinal degeneration, right eye - Secondary vitreoretinal degeneration, bilateral H35.463 H35.50 - Unspecified hereditary retinal dystrophy - Dystrophies primarily involving the retinal pigment H35.54 epithelium H35.61 - Retinal hemorrhage, right eye - Retinal hemorrhage, bilateral H35.63 H35.70 Unspecified separation of retinal layers H35.711 - Central serous chorioretinopathy, right eye - Central serous chorioretinopathy, bilateral H35.713 H35.721 - Serous detachment of retinal pigment epithelium, right eye - Serous detachment of retinal pigment H35.723 epithelium, bilateral H35.731 - Hemorrhagic detachment of retinal pigment epithelium, right eye - Hemorrhagic detachment of H35.733 retinal pigment epithelium, bilateral H35.81 - Retinal edema - Other specified retinal disorders H35.89 H36 Retinal disorders in diseases classified elsewhere H46.01 - Optic papillitis, right eye - Optic papillitis, bilateral H46.03 H46.11 - Retrobulbar neuritis, right eye - Retrobulbar neuritis, bilateral H46.13 H46.2 - Nutritional optic neuropathy - Unspecified optic neuritis H46.9 H47.011 - Ischemic optic neuropathy, right eye - Ischemic optic neuropathy, bilateral H47.013 H47.021 - Hemorrhage in optic nerve sheath, right eye - Hemorrhage in optic nerve sheath, bilateral H47.023 H47.031 - Optic nerve hypoplasia, right eye - Optic nerve hypoplasia, bilateral H47.033 H47.091 - Other disorders of optic nerve, not elsewhere classified, right eye - Other disorders of optic nerve, H47.093 not elsewhere classified, bilateral H47.10 - Unspecified papilledema - Papilledema associated with retinal disorder H47.13 H47.141 - Foster-Kennedy syndrome, right eye - Foster-Kennedy syndrome, bilateral H47.143 H47.20 - Unspecified optic atrophy - Primary optic atrophy, bilateral H47.213 H47.22 - Hereditary optic atrophy - Glaucomatous optic atrophy, bilateral H47.233 H47.291 - Other optic atrophy, right eye - Other optic atrophy, bilateral H47.293 H47.311 - Coloboma of optic disc, right eye - Coloboma of optic disc, bilateral H47.313 H47.321 - Drusen of optic disc, right eye - Drusen of optic disc, bilateral H47.323 H47.331 - Pseudopapilledema of optic disc, right eye - Pseudopapilledema of optic disc, bilateral H47.333 H47.391 - Other disorders of optic disc, right eye - Other disorders of optic disc, bilateral H47.393 L10.4 Pemphigus erythematosus Poisoning by antimalarials and drugs acting on other blood protozoa, accidental (unintentional), T37.2X1A initial encounter Poisoning by antimalarials and drugs acting on other blood protozoa, intentional self-harm, initial T37.2X2A encounter T37.2X3A Poisoning by antimalarials and drugs acting on other blood protozoa, assault, initial encounter T37.2X4A Printed on 8/29/2017. Page 13 of 16 ICD-10 Description Codes Poisoning by antimalarials and drugs acting on other blood protozoa, undetermined, initial encounter T37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter T37.2X6A Underdosing of antimalarials and drugs acting on other blood protozoa, initial encounter Z79.899 Other long term (current) drug therapy

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Sources of Information

1. Jampel HD, Singh K, Lin SC, et al. Assessment of visual function in glaucoma: A report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(5):986-1002. 2. Horn FK, Kaltwasser C, Jünemann AG, et al. Objective perimetry using a four-channel multifocal VEP system: correlation with conventional perimetry and thickness of the retinal nerve fibre layer. Br J Ophthalmol. 2012;96(4):554-559. 3. Pillai C, Ritch R, Derr P, Gonzalez A, Kopko Cox L, Siegfried J, Liebmann JM, Tello C. Sensitivity and specificity of short-duration transient visual evoked potentials (SD-tVEP) in discriminating normal from glaucomatous eyes. Invest Ophthalmol Vis Sci. 2013;54(4):2847-2852. 4. Banitt MR, Ventura LM, Feuer WJ, et al. Progressive loss of retinal ganglion cell function precedes structural loss by several years in glaucoma suspects. Invest Ophthalmol Vis Sci. 2013 Mar 28;54(3):2346 -52. 5. Jafarzadehpour E, Radinmehr F, Pakravan M, Mirzajani A, Yazdani S. Pattern Electroretinography in Glaucoma Suspects and Early Primary Open Angle Glaucoma. J Ophthalmic Vis Res. 2013;8(3):199-206. 6. Ventura LM, Golubev I, Feuer WJ, Porciatti V. Pattern electroretinogram progression in glaucoma suspects. J Glaucoma. 2013;22:219–225. 7. American Academy of Ophthalmology (AAO), Glaucoma Panel. Primary Open-Angle Glaucoma Suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. Accessed 8/24/16 http://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf. 8. American Academy of Ophthalmology (AAO), Glaucoma Panel. Primary Open-Angle Glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. Accessed 8/24/16 http://www.aaojournal.org/article/S0161-6420(15)01276-2/pdf. 9. Jacobs DS. Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis. UpToDate Inc., Waltham, MA. Last accessed 8/24/16. 10. Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF, American Academy of Ophthalmology. Recommendations on screening for Chloroquine and Hydroxychloroquine retinopathy (2016 Revision). Ophthalmology. 2016 Jun;123(6):1386-1394. 11. Aetna policy #0854 Electroretinography. Last accessed 8/30/16. http://www.aetna.com/cpb/medical/data/800_899/0854.html 12. BCBS FL policy #01-92000-28 Electroretinography. Last accessed 12/12/16. http://mcgs.bcbsfl.com/?doc=Electroretinography 13. Anthem policy CG-MED-50. Visual, Somatosensory and Motor Evoked Potentials. Last accessed 8/30/16. https://www.anthem.com/medicalpolicies/guidelines/gl_pw_c160720.htm 14. Noridian LCD Sensory Evoked Potentials & Intraoperative Neurophysiology Monitoring (L34072). 15. Novitas LCD Neurohysiology Evoked Potentials (NEPs) (L34975). 16. Cahaba LCD Medicine: Neurohysiology Evoked Potentials (NEPs) (L34266). 17. American Optometric Association (AOA), Optometric Clinical Practice Guideline. Care of the Patient with Primary Angle Closure Glaucoma. St. Louis, MO:1994. 18. American Optometric Association (AOA), Optometric Clinical Practice Guideline. Care of the Patient with Open Angle Glaucoma. St. Louis, MO:2011. 19. Aetna policy #0181 Evoked Potential Studies. Last accessed 12/12/2016. http://www.aetna.com/cpb/medical/data/100_199/0181.html

Printed on 8/29/2017. Page 14 of 16 20. International Society for Clinical Electrophysiology of Vision (VISCEV): A Guide To Procedures. Visual Eelectrodiagnostics A Guide To Procedures. Accessed 12/12/2016. http://www.iscev.org/standards/proceduresguide.html. 21. Bach M, Unsoeld AS, Philippin H. Pattern ERG as an early glaucoma indicator in : a long-term, prospective study. Invest Ophthalmol Vis Sci. 2006;47:4881–4887. 22. Bode SF, Jehle T, Bach M. Pattern electroretinogram in glaucoma suspects: new findings from a longitudinal study. Invest Ophthalmol Vis Sci. 2011;52:4300–4306. 23. Ventura LM, Feuer WJ, Porciatti V. Progressive loss of retinal ganglion cell function is hindered with IOP- lowering treatment in early glaucoma. Invest Ophthalmol Vis Sci. 2012:53(2):659–663. 24. Karaskiewicz J, Penkala K, Mularczyk M, Lubinski W. Evaluation of retinal ganglion cell function after intraocular pressure reduction measured by pattern electroretinogram in patients with primary open-angle glaucoma. Doc Ophthalmol. 2017:134:89–97. 25. Ventura LM, Porciatti V. Restoration of retinal ganglion cell function in early glaucoma after intraocular pressure reduction: a pilot study. Ophthalmology. 2005;112:20–27. 26. Ventura LM, Sorokac N, De Los Santos R, Feuer WJ, Porciatti V. The relationship between retinal ganglion cell function and retinal nerve fiber thickness in early glaucoma. Invest Ophthalmol Vis Sci. 2006; 47:3904–3911. 27. Nebbioso M, Gregorio FD, Prencipe L, Pecorella I. Psychophysical and electrophysiological testing in ocular hypertension. Optom Vis Sci. 2011;88:E928–E939. 28. Uva MG, DiPietro M, Longo A, Lauretta K, Reibaldi M, Reibaldi A. Pattern ERG and RNFL thickness in hypertensive eyes with normal blue-yellow visual field. Graefes Arch Clin Exp Ophthalmol. 2013;251:839–845. 29. Parisi V, Centofanti, M, Ziccardi L, et al. Treatment with citicoline eye drops enhances retinal function and neural conduction along the visual pathways in open angle glaucoma. Graefes Arch Clin Exp Ophthalmol. 2015;253:1327–1340.

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Revision Revision Reason(s) for History History Revision History Explanation Change Date Number Based on two reconsideration requests to provide coverage of electroretinogram (ERG) and pattern electroretinogram (PERG) testing for glaucoma – March 2017, references have been added to the LCD. No changes were made in coverage. • Reconsideration 03/16/2017 R2 DATE (08/01/2017): At this time 21st Century Cures Act will Request apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. ICD-10-CM codes H47.521, H47.522, H53.011-H53.013, • Provider 03/16/2017 R1 H53.021 – H53.023 and H53.031 – H53.033 have been added Education/Guidance to the Group 1 code list for CPT code 95930. Back to Top Associated Documents

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Printed on 8/29/2017. Page 15 of 16 Public Version(s) Updated on 07/21/2017 with effective dates 03/16/2017 - N/A Updated on 05/04/2017 with effective dates 03/16/2017 - N/A Updated on 03/10/2017 with effective dates 03/16/2017 - N/A Back to Top Keywords

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