TRANSMITTAL #:  132

DATE:  04/10/2013

TRICARE CHANGE #:  C-121

CHAMPVA POLICY MANUAL

CHAPTER:  2

SECTION:  10.6

TITLE:  OPHTHALMOLOGICAL SERVICES

AUTHORITY: 38 CFR 17.270(a) and 17.272(a)

RELATED AUTHORITY: 32 CFR 199.4(c)(2)(xvi)(e)(6), and (g)(50)

I. EFFECTIVE DATE(S)

October 1, 1984

II. PROCEDURE CODE(S)

CPT Codes:  76511-76529, 92002-92014, 92018-92060, 92071-92358, and 92371

III. DESCRIPTION(S)

A.      Ophthalmological services may include an eye examination and other specialized services.  The purpose of the examination is to diagnose or treat a medical or surgical condition of the eye and associated structures.

IV. POLICY

A.      Medically necessary ophthalmological services, which may include refractive services, that are provided in connection with a medical or surgical condition or to the medical or surgical treatment of a covered illness or injury are covered.  Medical documentation is required from the physician supporting the specialized ophthalmolological services.  Coverage of ophthalmological services is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition.  

B.      Heidelberg Retina Tomography (HRT) and Scanning Laser Polarimetry (GDX) to diagnose and monitor progression of suspected glaucoma is covered.

C.      Optical Coherence Tomography (OCT) to diagnose and monitor progression of suspected retinal disease is covered.

V. EXCLUSION(S)

A.      Canaloplasty in the treatment of glaucoma is unproven.

B.      The following routine eye examinations performed for the purpose of prescribing, fitting or changing eyeglasses, are not covered benefits.  

1.       Eye exam, new patient.

2.       Eye exam, established patient.

3.       Eye exam and treatment.

4.       Refraction.

5.       Ocular function screen.

6.       Visual acuity screen.

7.       A routine eye examination, which usually includes refractive services, that is not related to a medical or surgical condition or to the medical or surgical treatment of a covered illness or injury is not covered.  ICD (International Classification of Diseases)-9 codes V72.0; 360.21; 367.0; 367.1; 367.2; 367.20; 367.21; 367.22; 367.3; 367.31; 367.32; 367.4; 367.51; 367.52; 367.53; 367.9; and 368.13 are often used to identify a routine eye examination.

C.      Orthoptics, also known as vision training, vision therapy, eye exercises, or eye therapy.

*END OF POLICY*