Download Glaucoma Treatment

Rule Category:
Medical
Ref: No:
2013-MN-0004
`
Version Control:
Version No. 2.0
Effective Date:
May 2013
Revision Date:
August 2015
Glaucoma Management
Adjudication Rule
Table of content
Abstract Scope Adjudication Policy
Page 1
Page 2 Page 2
Adjudication examples
Page 3
Denial codes
Page 3
Appendices
Page 4
Approved by:
Daman
Abstract
Responsible:
Medical Strategy &
Development Department
For Members
Glaucoma is an eye disease that causes progressive damage to the optic nerve, the
nerve that carries visual information to the brain, thereby potentially leading to
blindness, if untreated. It is usually associated with an increase in the fluid pressure in
the eye; the progressive loss of vision can be alleviated by reducing the fluid pressure.
Daman covers diagnostic and treatment services for glaucoma, if medically necessary,
for all health insurance plans administered by Daman, as per policy terms and conditions
For Medical Professionals
Daman covers management of glaucoma, as per medical necessity.
For Visitor‟s plan, only acute angle-closure glaucoma is covered, as an emergency
treatment, and should be supported with appropriate documentation.
Daman covers laser/surgical treatment for open-angle glaucoma according to the
medically necessary criteria mentioned in the “Eligibility/Coverage criteria” section of this
adjudication rule.
Regarding serial tonometry, it will only be covered if the medically relevant criteria are
met, as listed in the “Eligibility/Coverage criteria” section, and if performed serially, and
not as a one-time measurement. It requires at least three measurements done at
different times on the same day or several days and only one service should be claimed
no matter how many times it is performed over one or several days.
Daman does not cover experimental and unproven treatments (as listed in the Noncoverage section), since their safety and efficacy is not proven and supported by
international best practice medical guidelines.
Related Adjudication Rules:
None
Disclaimer
By accessing these Daman Adjudication Rules
(the “AR”), you acknowledge that you have read
and understood the terms of use set out in the
disclaimer below:
The information contained in this AR is intended
to outline the procedures of adjudication of
medical claims as applied by the National Health
Insurance Company – Daman PJSC (hereinafter
“Daman”). The AR is not intended to be
comprehensive, should not be used as treatment
guidelines and should only be used for the
purpose of reference or guidance for adjudication
procedures and shall not be construed as
conclusive. Daman in no way interferes with the
treatment of patient and will not bear any
responsibility for treatment decisions interpreted
through Daman AR. Treatment of patient is and
remains at all times the sole responsibility of the
treating Healthcare Provider. This AR does not
grant any rights or impose obligations on Daman.
The AR and all of the information it contains are
provided "as is" without warranties of any kind,
whether express or implied which are hereby
expressly disclaimed.
Under no circumstances will Daman be liable to
any person or business entity for any direct,
indirect, special, incidental, consequential, or
other damages arising out of any use of, access
to, or inability to use or access to, or reliance on
this AR, including but without limitation to, any
loss of profits, business interruption, or loss of
programs or information, even if Daman has been
specifically advised of the possibility of such
damages. Daman also disclaims all liability for
any material contained in other websites linked to
Daman website.
This AR is subject to the laws, decrees, circulars
and regulations of Abu Dhabi and UAE.
Any
information provided herein is general and is not
intended to replace or supersede any laws or
regulations related to the AR as enforced in the
UAE issued by any governmental entity or
regulatory authority, or any other written
document governing the relationship between
Daman and its contracting parties.
This AR is developed by Daman and is the
property of Daman and may not be copied,
reproduced, distributed or displayed by any third
party without Daman‟s express written consent.
This AR incorporates the Current Procedural
Terminology and Current Dental Terminology
(CPT® and CDT®, which is a registered
trademark of the American Medical Association
(“AMA”), and the American Dental Association
(“ADA”) respectively), and the CPT and CDT codes
and descriptions belong to the AMA. Daman
reserves the right to modify, alter, amend or
obsolete the AR at any time by providing one
month prior notice.
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Glaucoma Management
Scope
Requirements for Coverage
This guideline highlights the medically necessary
services required for the diagnosis and treatment of
glaucoma
for
all
health
insurance
plans
administered by Daman.
ICD and CPT codes must be coded to the highest
level of specificity.
Non-Coverage
Diagnostic and treatment services for glaucoma are
not covered for the Visitor‟s Plan (exceptions are
highlighted in the coverage section (i.e. medical
emergency)).
Adjudication Policy
Eligibility / Coverage Criteria
Daman does not cover the following treatments,
because they are considered to be experimental
and their safety and efficacy is not approved or
supported by peer-reviewed medical literature:
Diagnostic and treatment services for glaucoma are
covered for all health insurance plans administered
by Daman, as per policy terms and conditions.
In case of the Visitor‟s plan, only the emergency
treatment of „acute angle closure glaucoma‟ is
covered and it should be supported with
documentation/interpretation and reports (i.e.
gonioscopic findings, tonometry, biomicroscopic
evaluation of the anterior chamber, opthalmoscopy
for optic nerve evaluation etc.).

Viscocanalostomy

Ab interno trabeculectomy (trabectome)

Transciliary fistulization

Un-proven shunts for glaucoma
Pharmacological management
Payment and Coding Rules
Daman covers pharmacological management of
glaucoma based on medical necessity and in
accordance with international best practice.
Please apply HAAD payment rules and regulations
and relevant coding manuals for ICD, CPT, etc.
The following classes of drugs will be covered for
the treatment of glaucoma:
A. General ophthalmological services

Billing of Glaucoma Related Services:
B. Evaluation and management (E/M) services
Topical prostaglandin analogues (e.g.
latanoprost etc)

Topical beta blockers (e.g. timolol, carteolol,
betaxolol etc)

Topical carbonic anhydrase inhibitors (e.g.
brinzolamide, dorzolamide etc)

Topical alpha-2 adrenergic agonists (e.g.
apraclonidine, brimonidine etc)

The following services are included in the above
mentioned ophthalmological examination services
and cannot be claimed for separately, if performed
(i.e. no separate codes are available for the
following procedures):
Note: This list may not be all-inclusive.

Topical cholinergic agonists (e.g. pilocarpine,
carbachol etc)
Visual acuity (excluding determination of
refractive state-92015)


Cholinesterase Inhibitors (e.g. echothiopate
etc)
Gross visual field test (excluding visual field
92081 - 92083)

External ocular exam

Hyperosmotics (e.g. mannitol, glycerin etc)

Adnexal exam

Corticosteroids – if glaucoma is associated
with inflammation

Retinoscopy

Slit lamp examination
Topical Mitomycin

Tonometry, as a component of general eye
examination (excluding serial tonometry)

Routine ophthalmoscopic examination
(excluding extended opthalmoscopy)

Keratometry

Corneal staining/sensitivity

Fundus examination (excluding fundus
photography)

Surgical treatment
Daman will cover laser/surgical treatment for openangle glaucoma if any of the following criteria are
met and clearly documented:

No significant reduction in the IOP to prevent
vision loss despite pharmacological therapy.

There is progression of optic nerve head
damage/visual field defect despite
pharmacological therapy.
C. Special ophthalmological services:
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Glaucoma Management
Special ophthalmological services may be reported
in addition to the general ophthalmological services
and must be supported with documentation.
Procedures under 92020, 92250, 92100, 92133,
92134 and 92083 will be covered yearly for
glaucoma and glaucoma suspects and repeat
coverage is subject to medical necessity.
The following are some of the common special
services to be reported with a diagnosis of
Glaucoma
CPT-4 Code
Billing rule
Gonioscopy
(92020)
Only one unit of service should be
reported regardless of whether one
or both eyes have been tested
Adjudication Examples
Example 1
Question: : A 50 year old female, holding Thiqa
Plan, is a suspected case of glaucoma and the
physician claims for 6 sessions of serial tonometry
(3 for each eye) performed on the same day, to
confirm the diagnosis of glaucoma. Will this claim
be approved?
Serial tonometry will only be
covered for the following medically
necessary indications:
o
Monitor IOP during the
course of medical treatment
of an attack of acute angleclosure glaucoma
o
Assess diurnal variations of
intraocular pressure
o
To confirm the diagnosis of
glaucoma
Answer: Only ONE unit of service for serial
tonometry will be covered (for both eyes and
regardless of the number of sessions performed).
Example 2
Question: A claim received for 35 year old male,
holding a Visitor‟s Plan, for beta blockers for
treatment of his chronic open angle-glaucoma. Will
this claim be approved?
Serial tonometry is covered only if
performed serially, and not as a
one-time measurement. It requires
at least three measurements done
at different times on the same day
or several days and only one
service should be claimed (on the
last service date*) no matter how
many times it is performed over
one or several days
Serial
Tonometry
(92100)
Answer: No, The member is not eligible for this
service; hence the claim will be rejected.
Denial codes
Only one unit of service should be
reported regardless of whether one
or both eyes have been tested
Code
Serial tonometry is not indicated in
the routine follow-up of glaucoma
and the monitoring of medication
for a chronic disease process.
Single tonometry in this instance is
included in the ophthalmology
service codes and is not payable
separately
Scanning
computerized
ophthalmic
diagnostic
imaging (9213292134)
Only one unit of service should be
reported regardless of whether one
or both eyes have been tested.
Extended
Opthalmoscopy
(92225, 92226)
Extended ophthalmoscopy is a
unilateral procedure, which means
each eye can be billed separately.
Visual field
examination
(92081-92083)
Only one unit of service should be
reported regardless of whether one
or both eyes have been tested.
Fundus
photography
(92250)
Only one unit of service should be
reported regardless of whether one
or both eyes have been tested.
Code description
MNEC-003
Service is not clinically indicated based on
good clinical practice
MNEC-004
Service is not clinically indicated based on
good clinical practice, without additional
supporting diagnoses/activities
MNEC-005
Service/supply may be appropriate, but too
frequent
NCOV-001
Diagnosis(es) is (are) not covered
NCOV-003
Service(s) is (are) not covered
Appendices
A. References
*The provider may claim the first and second sessions (or
any number of sessions) with zero claimed amounts if not
performed on the same day, and claim the third or last
session as one unit.
1.
AMA CPT Handbook
2.
National Institute for Health and Clinical
Excellence.
(2009).
Diagnosis
and
management of chronic open angle
glaucoma and ocular hypertension. National
Institute for Health and Clinical Excellence.
1 (1), 1-261.
3.
Drugs. (2012). Glaucoma Medications.
Available
at:
http://www.drugs.com/condition/glaucoma.
html. Last accessed 10th September 2012.
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Glaucoma Management
4.
American Academy of Ophthalmology.
(2011).
Novel
Glaucoma
Procedures.
Ophthalmic Technology Assessment. 1 (1),
1-15.
5.
American Optometric Association. (2009).
Serial
Tonometry.
Available
at:
http://www.aoa.org/x13181.xml.
Last
accessed 11th September 2012.
6.
Sue Vicchrilli. (2012). Savvy Coder: Coding
&
Reimbursement.
Available
at:
http://www.aao.org/publications/eyenet/20
0409/coder.cfm.
Last
accessed
11th
September 2012.
7.
Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O.,
San Bernardino, Calif. (2002). New Tests
Becoming Standard of Care. Available:
http://www.optometricmanagement.com/ar
ticleviewer.aspx?articleid=70522.
Last
accessed 11th September 2012.
8.
American Optometric Association. (2001).
Primary
Angle
Closure
Glaucoma.
Optometric Clinical Practice Guideline. 1
(1), 1-29.
FDA. (25th June 2012). FDA approves first
glaucoma stent for use with cataract
surgery.
Available
at:
http://www.fda.gov/NewsEvents/Newsroom
/PressAnnouncements/ucm309667.htm.
Last accessed 24th September 2012.
9.
10. Blue Cross of Idaho. (2012). Aqueous
Shunts
for
Glaucoma.
Available
at:
https://www.bcidaho.com/providers/medic
al_policies/oth/mp_90321.asp.
Last
accessed 24th September 2012.
11.
Alan Homestead, OD. (March 2012).
GLAUCOMA CODING INSIGHTS. Available
at:
http://www.optometricoffice.com/ME2/Audi
ences/dirmod.asp?sid=&nm=Insight&type=
Publishing&mod=Publications%3A%3AArticl
e&mid=8F3A7027421841978F18BE895F87
F791&tier=4&id=0A172A00E37D4095B61A
D2B76B766826&A. Last accessed 10th
December 2012.
B. Revision History
Date
Change(s)
01-07-13
V1.1: New template
15-07-14
1.
2.
V 2.0
Disclaimer updated as per system
requirements
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.:
TEMP/MSD-008
Version No.: 1
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Date of Issue:
08.05.2013
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