Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma (suspected)
Issue under review: Vision testing
The insurer denied the vision testing. 
The denial is overturned. 

The patient is a female glaucoma suspect for whom coverage of an outpatient established visit (99213) with visual field testing (92083) and fundus photography (92250) is requested. 

An optometric exam documents the patient returning for follow up of nuclear cataracts of both eyes. Ocular history was also notable for dry eye syndrome, hyperopia, presbyopia, and glaucoma suspected (based on large cup/disc ratios). On exam, vision was corrected to 20/25 OD (right eye) and 20/20 OS (left eye). An exam documents that an OCT (optical coherence tomography) was performed and found thinning of superior quadrants OS>OD. Vision was corrected to 20/25 OD and 20/20 OS.  Intraocular pressures were 18 mm Hg OD and 17 mm Hg OS. Visual field testing and fundus photography/optic disc photos were performed. Visual field testing did not identify defects consistent with glaucoma suspect.  Photography did confirm deep cups consistent with glaucoma suspect. 

Based on this testing, it was recommended that the patient return in six months for repeat optic nerve OCT and one year for repeat visual field testing. Coverage of these services provided by an optometrist were previously denied as not medically necessary upon review by a family medicine provider. The Plan does not cover routine vision services. 

Yes, the testing was medically necessary per standard of care for a patient suspected of having glaucoma.

In this case, coverage was denied for testing performed on a patient suspected of having glaucoma based on optic nerve appearance.  Such services were denied as they were considered routine vision services rather than medical. This determination is not consistent with current standard of care as reflected in the American Academy of Ophthalmology's Preferred Practice Patterns (PPP), which states that "A diagnosis for primary open-angle glaucoma (POAG) suspect is established by the presence of one of the following conditions: a consistently elevated intraocular pressure (IOP), a suspicious-appearing optic nerve, or abnormal visual field." 

In this case, the patient was identified as being a glaucoma suspect (a medical diagnosis) based on optic nerve appearance. According to the PPP, "The decision to treat a POAG suspect patient may depend on evidence of optic nerve changes, any visual field defect, level of IOP, and other associated risk factors. The recommended ophthalmic evaluation focuses specifically on the following elements in the comprehensive adult medical eye evaluation: visual acuity measurement, pupil examination, anterior segment examination, intraocular pressure (IOP) measurement, gonioscopy, optic nerve head (ONH) and retinal nerve fiber layer (RNFL) examination, and fundus examination. Important ophthalmic testing includes the following components: central corneal thickness measurement, visual field evaluation, and ONH and RNFL imaging...The appearance of the optic nerve should be documented...Computer-based imaging and stereoscopic photography of the optic nerve provided different information about optic nerve status, and both are useful to a good clinical examination." 

Therefore, given the above, the services/testing performed was medically necessary per standard of care for this glaucoma suspect.