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Date Printed: December 17, 2017: 04:25 PM

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Subject: Scanning Computerized Ophthalmic Diagnostic Imaging

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This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

Scanning Computerized Ophthalmic Diagnostic Imaging, or SCODI, includes several types of eye exams. Using light, optics and computers, these exams scan and create detailed images of the inner eye. SCODI exams may help your doctor evaluate certain eye disorders, such as glaucoma or macular degeneration.

Confocal Scanning Laser Ophthalmoscopy (CSLO)

In this technique, your doctor uses a scanning laser microscope. A laser beam first passes through a special opening then focuses on the area within your eye to scan. The microscope allows your doctor to view the area. A computer records that view. CSLO creates high-contrast images that may help your doctor estimate the thickness of the nerve fiber layer in the retina. The Heidelberg Retinal Tomograph is a common example of CSLO.

Scanning Laser Polarimetry (SLP)

In SLP, a laser beam illuminates the optic nerve within your eye. As the laser light passes through the nerve, its polarization properties change. The SLP system then directly measures and evaluates the change. This gives an accurate measure of the thickness of the nerve fiber layer in the retina. Usually, the pupil of your eye does not require dilating. An SLP exam is also relatively quick. Some SLP systems can compare the results of your exam to a comparable normal standard. GDx® is a common type of scanning laser polarimeter.

Optical Coherence Tomography (OCT)

OCT works in much the same way as an ultrasound scan. Rather than sound though, the technique uses near-infrared light. This exam creates 3-dimensional, cross-sectional images of your retina’s nerve fiber layer. These images provide a measure of thickness. In this type of exam, dilation of your eye is required.

Visit the Clinical View of this guideline for more information.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

SCODI, Posterior Segment may be covered if certain requirements are met:

• To document the appearance of the optic nerve if you have mild to moderate glaucoma or if glaucoma is suspected.

To document the appearance of the optic nerve if you have advanced glaucoma, if visual field testing can’t be performed.

• To document the appearance of the optic nerve and retina if you have a condition that affects the optic nerve and retina.

SCODI, Posterior Segment is considered experimental or investigational:

• When performed solely as a screening method

• To confirm a known diagnosis of glaucoma

• Refer to the Clinical View for other indications not listed.

The clinical evidence is not sufficient to support using SCODI, Posterior Segment to make decisions for these conditions.

SCODI, Anterior Segment is considered experimental or investigational.

The available published clinical evidence does not support the clinical value of SCODI, Anterior Segment.

Visit the Clinical View of this guideline for specific coverage information.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: December 17, 2017: 04:25 PM