92020
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.36
Facility
$16.37
Non-Facility
$26.72
Documentation Required
- For billed visual field and imaging services, interpretation and report must be present (CPT descriptors: 'with interpretation and report')
- Clinical records demonstrating medical necessity for evaluation of primary open-angle glaucoma (e.g., findings from ophthalmic exam, gonioscopy results, visual field test results, optic nerve/RNFL imaging) to justify testing
- When a service/technology is billed that is listed as experimental/investigational or not covered (see limitations), documentation must support why the service is being used; however, Aetna considers those services investigational and not covered per policy
- Medical record documentation that supports the diagnosis of primary open-angle glaucoma (ICD-10 H40.1110 - H40.1194) when ordering/performing covered glaucoma tests
Key Coverage Criteria
- No explicit 'Indications' or 'Covered Indications' section appears in this document excerpt.
- Inferred (based on references cited): diagnosis and monitoring of glaucoma (including open-angle glaucoma and normal-tension glaucoma).
- Inferred (based on references cited): measurement/monitoring of intraocular pressure (tonometry), including clinic and home tonometry (e.g., iCare Home tonometer).
- Inferred (based on references cited): assessment of corneal biomechanical properties (e.g., corneal hysteresis, corneal resistance factor) as risk factors or biomarkers in glaucoma evaluation.
- Inferred (based on references cited): measurement/analysis of ocular blood flow (pulsatile ocular blood flow, ocular blood flow tonometer) in ocular disease evaluation.
- Inferred (based on references cited): use of visual electrophysiology (visual evoked potentials, multifocal VEP) and other objective perimetry techniques for detection/diagnosis of glaucomatous field defects.
2 Active Policies
AMBETTER-CP.VP.31 — Gonioscopy
AETNA-CPB-0622 — Glaucoma Testing
Related Codes
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