Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules state that Visual field examinations will be considered medically necessary under the following conditions: 1. Disorder of the eyelids potentially affecting the visual field. 2. A documented diagnosis of glaucoma. Stabilization or progression of glaucoma can be monitored by a visual field examination, or by such services as scanning computerized ophthalmic diagnostic imaging. This evaluation must be performed at regular intervals to determine that the prescribed management is adequately controlling progression of disease to the degree possible. The frequency of such examinations is dependent on clinical judgment as well as the variability of intraocular pressure measurements (i.e., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve. 3. A diagnosis of glaucoma is suspected with supporting evidence documented. A suspected diagnosis of glaucoma is evidenced by an increase in intraocular pressure over time, intraocular pressures of 22 mm Hg or more, asymmetric intraocular measurements of greater than 2 mm Hg between the two eyes, or optic nerves suspicious for glaucoma, which may be manifested as asymmetrical cupping, a change in the cup-to-disc ratio over time, disc hemorrhage, or an absent, thinned, or notched neural rim. Additional possible indicators of glaucoma suspicion are fallout of the retinal nerve fiber layer, optic atrophy (pallor of the optic nerve), corneal endothelial pigment deposits (Krukenburg's Spindle), dense pigmentation of the trabecular meshwork as evidenced by gonioscopy, pseudoexfoliation of the lens, or dense exfoliative deposits on the trabecular meshwork as evidenced by gonioscopy. 4. A documented disorder of the optic nerve, the neurologic visual pathway, or retina. Patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients who are about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field would not be indicated. 5. A recent intracranial hemorrhage, an intracranial mass, or a recent measurement of increased intracranial pressure with or without visual symptomatology. 6. A recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia, or giant cell arteritis. 7. A history of a cerebral aneurysm, pituitary tumor, occipital tumor, or other condition potentially affecting the visual fields. 8. A visual field defect demonstrated by gross visual field testing (e.g., confrontation testing). 9. An initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital ptosis. 10. A disorder of the orbit, potentially affecting the visual field (e.g. orbital tumor, thyroid disease, etc.). 11. A significant eye injury. 12. Unexplained visual loss which may be described as "trouble seeing or vision going in and out." 13. A pale or swollen optic nerve documented by a recent examination. 14. New functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things). 15. Medication treatment (e.g., hydroxychloroquine) which has a high risk of potentially affecting the visual system. 16. Initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) L34615, Visual Fields. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.