![]() Annual follow-up of thyroid ophthalmopathy.Nerve fiber layer testing or analysis (confocal laser scanning tomography with polarimetry)įootnote1 * In addition to annual screening that should begin after 5 years of use (or sooner it there are unusual risk factors), a baseline study of optic nerve and retinal imaging is considered medically necessary before initiation of chloroquine, hydroxychloroquine, or vigabatrin therapy.Īetna considers optic nerve and retinal imaging methods experimental and investigational for the following (not an all-inclusive list):.Note: Accepted optic nerve and retinal imaging methods include the following: Optic nerve imaging for glaucoma more frequently than once per year is considered not medically necessary. Other diseases where the optic nerve head and retina have been affected.Vogt-Koyanagi-Haradas (to quantify subretinal fluid and to follow individuals during treatment).Vitreomacular traction and vitreomacular adhesion.Screening and monitoring for chloroquine (Aralen), ethambutol (Myambutol), ezogabine (Potiga), hydroxychloroquine (Plaquenil), ponatinib (Iclusig), siponimod (Mayzent), and vigabatrin (Sabril) toxicity Footnote1*.Non-arteritic anterior ischemic optic neuropathy.Cystoid macular edema following cataract surgery.This Clinical Policy Bulletin addresses optic nerve and retinal imaging methods.Īetna considers optic nerve and retinal imaging methods medically necessary for documenting the appearance of the optic nerve head and retina in the following diagnoses/individuals: Number: 0344 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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