**Abstract:**  
  
 _Fluorescein_  
  
Fluorescein angiography is used in the diagnosis and treatment of a wide range
of ocular disorders. Its visible fluorescence 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 (ICG) 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, ICG 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. ICG
is effective in the diagnosis and treatment of ill-defined choroidal
neovascularization (e.g., associated with age related macular degeneration
(AMD). It is also useful in the evaluation 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 AMD. 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_  
  
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 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_  
  
ICG 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.  
  
ICG 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.  
  
 **Other Comments:**  
  
Limitation of liability and refund requirements apply when denials are based
on medical necessity. The provider/supplier must notify the beneficiary in
writing, prior to rendering the service, if the provider/supplier is aware
that the test, item or procedure may not be considered medically necessary by
Medicare. The limitation of liability and refund requirements do not apply
when the test, item or procedure is statutorily excluded, has no Medicare
benefit category or is rendered for screening purposes.  
  
For outpatient settings other than Comprehensive Outpatient Rehabilitation
Facilities (CORFs), references to "physicians" throughout this policy include
non-physicians, such as nurse practitioners, clinical nurse specialists and
physician assistants. Such non-physician practitioners, with certain
exceptions, may certify, order and establish the plan of care as authorized by
State law. (See Section **_CMS National Coverage Policy_** ).