Local Coverage Determination (LCD)

Ophthalmic Angiography (Fluorescein and Indocyanine Green)

L34175

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

LCD Information

Document Information

LCD ID
L34175

LCD Title
Ophthalmic Angiography (Fluorescein and Indocyanine Green)

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 06/06/2024

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

Limited coverage as outlined in coverage and indication section.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Fluorescein

Fluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence on leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular disorders and monitoring treatment of conditions amenable to laser photocoagulation.

The dye is injected intravenously and serial photographs are taken through the pupil. While morphological characteristics alone may be pathognomonic of certain disease states, the timing of appearance of the dye in the choroid, in the central retinal artery and in the filling (or otherwise) of the quadrants have diagnostic implications.

Indocyanine Green

Indocyanine green dye is injected intravenously into the patient to highlight the vessels in the retina and the deeper tissue layer of the choroid. Under infrared light, Indocyanine Green fluoresces allowing the choroidal vessels to be visualized through the retinal pigment epithelium or in the presence of retinal or vitreous hemorrhage that would otherwise obscure visualization. Indocyanine green angiography (ICG) is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration). It is also useful in the evalution of feeder vessels, choroidal leakages in the late phase, and ruptures of the pigment epithelium.

Indications:

Fluorescein

Fluorescein angiography with interpretation is medically necessary as an adjunct to the diagnosis of chorioretinal vascular abnormalities especially relating to choroid neovascularization, noninfective vasculitis, and age related macular degeneration. It may also be appropriate in evaluating intraocular tumors, visual loss in systemic disease, acute exudative inflammations such as toxoplasmosis and optic disc edema. Medical necessity for such angiography would generally be in the context of a changing clinical picture. Fluorescein angiography may be useful in diabetic retinopathy in identifying ischemia and neovascularization, locating microaneurysms, and defining macular edema.

Fluorescein angiography following treatment, for example, of choroidal neovascularization (CNV) is necessary to monitor for recurrence or to detect additional treatable disease. Usually this is performed on the basis of a change in the clinical picture similar to the way it is employed prior to treatment. However, fluorescein angiography may be performed following treatment without clinical change in order to detect occult lesions. This will occur most often in CNV and very rarely in other diseases.

Indocyanine Green

Indocyanine green angiography (ICG) may be a valuable diagnostic adjunct to fluorescein angiography in the evaluation of the following conditions:

Retinal neovascularization
Choroid neovascularization
Serous detachment of retinal pigment epithelium
Hemorrhagic detachment of retinal pigment epithelium
Retinal hemorrhage

Limitations:

Fluorescein

Studies performed for screening will be denied by Medicare as not medically necessary.

Fluorescein angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner.

If excluded by State law, optometrists may not be reimbursed for fluorescein angiography.

Fluorescein angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic exam, in patients with unilateral Age related Macular Degeneration (AMD) or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each eye.

Indocyanine Green

Indocyanine green angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner.

If excluded by State law, optometrists may not be reimbursed for ICG angiography.

Indocyanine green is formulated with iodine and should not be used on patients who are allergic to iodine.

ICG for the evaluation of patients with background diabetic retinopathy is not considered to be a medically necessary service.

ICG angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each eye.

Studies performed for screening will be denied by Medicare as not medically necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
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Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information
N/A

Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC. is not responsible for the continuing viability of Web site addresses listed below.

Arevalo JF, Fuenmayor-Rivera D, Giral AE, Murcia E. Inflammation of the posterior uvea: findings on fundus fluorescein and indocyanine green angiography. Ocul Immunol Inflamm. 2006;14(3):171-9.

Bakri SJ, Sculley LA, Sing AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13. Available from:
http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Battaglia PM, Da Pozzo S, Ravalico G. Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration. Eye. 2004;18(7):685-90.

Bennett T. Fundamentals of fluorescein angiography indications and uses Ophthalmic Photographers Society. Available from: http://www.opsweb.org/OpPhoto/Angio/FA/FA3.html Accessed on 4/6/2007.

Bischoff P, Helbig H, Niederberger H, Torok B. Simultaneous ICG- and fluorescein-angiography for fundus examination. Klin Monatsbl Augenheilkd. 2000;216(2):120-5. German.

Bischoff PM, Niederberger HJ, Torok B, Speiser P. Simultaneous indocyanine green and fluorescein angiography. Retina. 1995;15(2):91-9.

Bottoini FG, Aandekerk AL, Deutman AF. Clinical application of digital indocyanine green videoangiography in senile macular degeneration. Graefes Arch Clin Exp Ophthalmol. 1994;232(8):458-68.

Bouchenaki N, Cimino L, Auer C, Tao Tran V, Herbort CP. Assessment and classification of choroidal vasculitis in posterior uveitis using indocyanine green angiography. Klin Monatsbl Augenheilkd. 2002;219(4):243-9.

Carrier Medical Director Ophthalmology Clinical Workgroup.

Cimino L, Auer C, Herbort CP. Indocyanine green videoangiography of multifocal Cryptococcus neoformans choroiditis in a patient with acquired immunodeficiency syndrome. Retina. 2001;21(5):537-41.

Coscas G, Coscas F, Soubrane G. Monitoring the patient after treatment: angiographic aspects of recurrence and indications for retreatment. J Fr Ophtalmol. 2004;27(1):81-92. French.

Dyer DS, Brant AM, Schachat AP, Bressler SB, Bressler NM. Angiographic features and outcome of questionable recurrent choroidal neovascularization. Am J Ophthalmol. 1995;120(4):497-505.

Guyer D. Principles of Indocyanine-Green Angiography, Retina Vitreous-Macula. W.B.Saunders. 1999;chapter 3:39-46.

Helbig H, Niederberger H, Valmaggia C, Bischoff P. Simultaneous fluorescein and indocyanine green angiography for exudative macular degeneration. Klin Monatsbl Augenheilkd. 2005;222(3):202-5.

Jampol, Lee M. Hypertension and Visual Outcome in the Macular Photocoagulation Study. Arch Ophthalmol. 1991;109(6):789-790.

Khairallah M, Ben Yahiak S, Attia S, et al. Indocyanine green angiographic features in multifocal chorioretinitis associated with West Nile virus infection. Retina. 2006;26(3):358-9.

Kramer M, Mimouni K, Priel E, Yassur Y, Weinberger D. Comparison of fluorescein angiography and indocyanine green angiography for imaging of choroidal neovascularization in hemorrhagic age-related macular degeneration. Am J Ophthalmol. 2000;129(4):495-500.

Mandava N. Principles of Fluorescein Angiography, Retina Vitreous-Macula. W.B.Saunders. 1999;chapter 4:29-38.

Mayfeild J. Who cares about the quality of diabetes care? Almost everyone! Clin Diabetes 1998;16(4).Available at: http://journal.diabetes.org/clinicaldiabetes/v16n41998/Mayfield.htm. Accessed July 21, 2006.

National Guideline Clearinghouse. Age-related macular degeneration. Limited revision. www.guideline.gov. Accessed July 21, 2006.

National Guideline Clearinghouse. Care of the patient with retinal detachment and related peripheral vitreoretinal disease. Available at: www.guideline.gov. Accessed July 21, 2006.

No authors listed. Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials. Macular Photocoagulation Study Group. Arch Ophthalmol. 1993;111(9):1200-9.

No authors listed. Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of age-related macular degeneration. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990;108(6):825-31.

No authors listed. Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989;107(3):344-52.

No authors listed, Recurrent choroidal neovascularization after argon laser photocoagulation for neovascular maculopathy. Macular Photocoagulation Study Group. Arch Ophthalmol. 1986;104(4):503-12.

Obana A, Gohto Y, Matsumoto M, Miki T, Nishiguti K. Indocyanine green angiographic features prognostic of visual outcome in the natural course of patients with age related macular degeneration. British Journal of Ophthalmology. 1999;83:429-437.

Other carrier policy (Empire Medical Services [effective 01/01/2006] L2170 R1). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed December 7, 2006.

Other carrier policy (First Coast Service Options [effective 10/01/2005] L1223 R3). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed July 21, 2006.

Other carrier policy (WPS [effective 10/01/2006] L17998 R9). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed December 7, 2006.

Other carrier policy (WPS [effective 10/01/2006] L17997 R6). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed July 21, 2006.

Other carrier policy: Riverbend Government Benefits Administrator Local Coverage Determination Indocyanine Green Angiography (#L1244). Accessed July 21, 2006.

Other carrier policy: Wheatlands Administrative Services Local Coverage Determination Indocyanine Green Angiography and Angioscopy (#L22232). Accessed July 21, 2006.

Pece A, Sannace C, Menchini U, et al. Fluorescein angiography and indocyanine green angiography for identifying occult choroidal neovascularization in age-related macular degeneration. Eur J Ophthalmol. 2005;15(6):759-63.

Regillo CD, Blade KA, Custis PH, O'Connell SR. Evaluating persistent and recurrent choroidal neovascularization: The role of indocyanine green angiography. Ophthalmology 1998;105:1821-1826.

Regillo CD, Benson WE, Maguire JI, Annesley WH Jr. Indocyanine green angiography and occult choroidal neovascularization. Ophthalmology. 1994;101(2):280-8.

Reichel E, Duker JS, Puliafito CA. Indocyanine green angiography and choroidal neovascularization obscured by hemorrhage. Ophthalmology. 1995;102:1871-1876.

Risk Factors for Neovascular Age-Related Macular Degeneration. The Eye Disease Case-Control Study Group, 1992. Arch Ophthalmology. 1992;110.

Sing RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195-208. Available at http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Slakter JS, Giovannini A, Yannuzzi LA, et al. Indocyanine green angiography of multifocal choroiditis. Ophthalmology. 1997;104(11):1813-9.

Stanga PE, Lim JI, Hamilton P. Indocyanine green angiography in chorioretinal diseases: indications and interpretation: an evidence-based update. Ophthalmology. 2003;110(1):15-21; quiz 22-3. Review

Sykes SO, Bressler NM, Maguire MG, Schachat AP, Bressler SB. Detecting recurrent choroidal neovascularization. Comparison of clinical examination with and without fluorescein angiography. Arch Ophthalmol. 1994;112(12):1561-6.

The Ophthalmic Photographers’ Society web page. (May 30, 2006). Fundamentals of fluorescein angiography indications and uses. Available at http://www.opsweb.org/Op-Photo/Angio/FA/FA#.htm. Accessed July 21, 2006.

Vadala M, Lodato G. Cillino S. Multifocal choroiditis: indocyanine green angiographic features. Ophthalmologica. 2001;215(1):16-21.

Van Liefferinge T, Sallet G, De Laey JJ. Indocyanine green angiography in cases of inflammatory chorioretinopathy. Bull Soc Belge Ophtalmol. 1995;257:73-81.

Watzke RC, Klein ML, Hiner CJ, Chan BK, Kraemer DF. A comparison of stereoscopic fluorescein angiography with indocyanine videoangiography in age-related macular degeneration. Ophthalmology. 2000;107:1601-1606.

Wolf S, Kirchof B, Reim M. The Ocular Fundus: From Findings to Diagnosis. Georg Thieme Verlag. 2006:11-13.

Bibliography

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
06/06/2024	R19	R19 Revision Effective: 06/06/2024 Revision Explanation: Annual Review, no changes were made. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Reivew )
05/25/2023	R18	R18 Revision Effective: 05/25/2023 Revision Explanation: Annual Review, no changes were made. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Review)
06/03/2021	R17	R17 Revision Effective: 06/02/2022 Revision Explanation: Annual Review, no changes were made At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Review)
05/27/2021	R16	R16 Revision Effective: 5/27/2021 Revision Explanation: Annual Review, no changes were made 5/17/2021:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Review)
10/31/2019	R15	R15 Revision Effective: N/A Revision Explanation: Annual Review, no changes made 5/27/2020:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Review)
10/31/2019	R14	R14 Revision Effective: 10/31/2019 Revision Explanation: Removed the NCD information from the CMS Nation Policy section, other comments information from coverage and indications information, and the associated information section from the policy and placed in to the billing and coding article. 10/24/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To Code Removal
09/19/2019	R13	R13 Revision Effective: 09/19/2019 Revision Explanation: Converted new policy template that no longer includes coding section based on CR 10901. No changes, approval only. 09/20/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To Code Removal
09/19/2019	R12	Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes. 09/13/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy	Revisions Due To Code Removal
09/19/2019	R11	R11 Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. Also, retired A52395 - Ophthalmic Angiography (Fluorescein and Indocyanine Green) –Supplemental Instructions Article. 09/12/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To Code Removal
06/06/2019	R10	R10 Revision Effective: 6-6-19 Revision Explanation: Annual review, defined AMD. DATE (05/19/2019): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Annual Review)
10/01/2016	R9	R9 Revision Effective:N/A Revision Explanation: Annual review no changes made. DATE (05/31/2018): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. R8 Revision Effective: N/A Revision Explanation: Annual review no changes made.	Other (Annual Review)
10/01/2016	R8	R7 Revision Effective: 10/01/2016 Revision Explanation: The following codes were left off during the annual ICD-10 update for 99240 group 3 diagnosis. H35.3211 H35.3212 H35.3213 H35.3221 H35.3222 H35.3223 H35.3231 H35.3232 H35.3233	Typographical Error
10/01/2016	R7	R7 Revision Effective: 10/01/2016 Revision Explanation: The following codes were deleted in the annual ICD-10 update E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, H34.811, H34.812, H34.813, H34.831, H34.832, H34.833, H35.31, H35.32. Replacement and new codes were added during annual ICD-10 update.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R6	R6 Revision Effective: N/A Revision Explanation: annual review no changes made	Other (annual review)
10/01/2015	R5	R5 Update to R4 Revision Effective: 10/01/2015 Revision Explanation: H47.10 was a typographical error and should have been the span H47.11-H47.13 and H47.141-H47.143 in group one. H47.10 will have a grace period until 03/14/2016 before being removed from the policy.	Typographical Error
10/01/2015	R4	R4 Revision Effective: 10/01/2015 Revision Explanation: H47.10 was a typographical error and should have been the span H47.11-H47.13 and added H47.141-H47.143 in group one.	Typographical Error
10/01/2015	R3	R3 Revision Effective: 10/01/2015 Revision Explanation: Added H59031-H59.033 for 92235 and corrected typo in group2 paragraph.	Reconsideration Request
10/01/2015	R2	R2 Revision Effective: 10/01/2015 Revision Explanation: Removed groups 3 and 4 since the secondary codes are listed in the stand alone group 1 diagnosis list these lists were added in error. Added E10.65 and E11.65 to group one list.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	R1 Revision Effective: 10/01/2015 Revision Explanation: Accepted revenue code description changes.	Other (revenue code description)

Associated Documents

Attachments
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Related Local Coverage Documents
Articles
A57069 - Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)

Updated On	Effective Dates	Status
05/31/2024	06/06/2024 - N/A	Currently in Effect	You are here
05/31/2024	05/25/2023 - 06/05/2024	Superseded	View
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Ophthalmic Angiography (Fluorescein and Indocyanine Green)

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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