BlueCross BlueShield of Tennessee Medical Policy Manual

Ophthalmologic Techniques for the Evaluation of Glaucoma

DESCRIPTION

Glaucoma is characterized by degeneration of the optic nerve (optic disc).  Elevated intraocular pressure (IOP) has long been thought to be the primary etiology, but the relation between IOP and optic nerve damage varies among individuals, suggesting a multifactorial origin.  The association between glaucoma and other vascular disorders such as diabetes or hypertension suggests vascular factors may play a role in glaucoma.

A comprehensive ophthalmologic exam is required for the diagnosis of glaucoma, but no single test is adequate to establish diagnosis.  Standard methods of evaluation include careful direct examination of the optic nerve using ophthalmoscopy or stereophotography, or evaluation of visual fields. There has been 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.

Optic Nerve/Retinal Nerve Fiber Layer (RNFL) Evaluation Techniques:

Techniques to measure ocular blood flow or ocular blood velocity have been proposed as evaluation tools for glaucoma; however, data for these techniques remain limited. Ocular blood flow and pulsatile ocular blood flow involve continuous monitoring of intraocular pressure that is converted into a volume measurement using the known relationship between ocular pressure and ocular volume.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Data regarding ocular blood flow, pulsatile ocular blood flow, and/or blood flow velocity are currently lacking and their relationship to clinical outcomes is not known.

SOURCES

American Academy of Ophthalmology. (2015). Preferred Practice Pattern. Primary open-angle glaucoma. Retrieved June 6, 2016 from http://one.aao.org/ppp.

American Academy of Ophthalmology. (2016). Preferred Practice Pattern. Primary open-angle glaucoma suspect. Retrieved March 22, 2017 from http://www.aaojournal.org.

American Academy of Ophthalmology. (2017, November). Preferred Practice Pattern. Glaucoma summary benchmarks. Retrieved March 5, 2018 from http://one.aao.org/ppp.

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2018). Ophthalmologic techniques that evaluate the posterior segment for glaucoma. (9.03.06). Retrieved March 5, 2018 from Blue Web. (15 articles and/or guidelines reviewed)

Mohindroo, C, Ichhpujani, P., Kumar, S. (2016). Current imaging modalities for assessing ocular blood flow in glaucoma. Journal of Current Glaucoma Practice, 10 (3), 104-112. (Level 4 evidence)

Palmetto, GBA. (2018, February) Local Coverage Determination (LCD): Scanning computerized ophthalmic diagnostic imaging (SCODI) (L34431). Retrieved March 5, 2018 from https://www.cms.gov.

U.S. Food and Drug Administration. (2006, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K063191. Retrieved February 24, 2012 from http://www.accessdata.fda.gov.

U.S. Food and Drug Administration. (2009, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082016. Retrieved February 24, 2012 from http://www.accessdata.fda.gov.

U.S. Food and Drug Administration. (2010, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K091404. Retrieved November 11, 2013 from http://www.accessdata.fda.gov. 

ORIGINAL EFFECTIVE DATE:  7/14/2012

MOST RECENT REVIEW DATE:  4/12/2018

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.