Clinical Policy: Special Ophthalmological Services - Reference Number WNC.CP.257

Oct 23, 2026

Uploaded by Logic

Clinical policy defines coverage criteria and non-covered situations for Special Ophthalmological Services under WellCare of North Carolina. It specifies when computerized corneal topography, sensorimotor examinations, contact lens fitting, SCODI imaging, ophthalmic biometry, fundus photography, and electrophysiologic retinal testing are medically necessary. Coverage depends on detailed clinical indications, including glaucoma severity staging, cataract-related measurements, corneal diagnoses, and neurologic or optic nerve assessment. The policy also lists exclusions, such as routine follow-up testing, certain timing with keratoplasty, advanced glaucoma scenarios, and services lacking stated Medicaid indications.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

AccessFree to download

Coverage Criteria

Computerized Corneal Topography

Sensorimotor Examination

Fitting of Contact Lens

SCODI (Scanning Computerized Ophthalmic Diagnostic Imaging)

Ophthalmic Biometry

Fundus Photography

Electrophysiologic Retinal Testing

Non-Covered Situations

Clinical Policy: Special Ophthalmological Services Reference Number: WNC.CP.257 Coding Implications Last Review Date: Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Note: When state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Description 1 Special ophthalmological services are special evaluations of part of the visual system, which go beyond the services included under general ophthalmological services or in which special treatment is given. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Policy/Criteria 1 I. It is the policy of WellCare of North Carolina® that Special Ophthalmological Services have the following coverage criteria: A. Computerized Corneal Topography is covered when it is determined to be medically necessary, the Member meets any of the following indications below AND the results will assist in defining further treatment: 1. Pre-operative evaluation of irregular astigmatism for intraocular lens power determination with cataract surgery; 2. Monocular diplopia; 3. Diagnosis ofkeratoconus; 4. Post-surgical or post-traumatic astigmatism, measuring at a minimum of 3.5 diopters; 5. Suspected irregular astigmatism based on retinoscopic streak or conventional keratometry; 6. Post-penetrating keratoplasty surgery; 7. Post-surgical or post-traumatic irregular astigmatism; 8. Corneal dystrophies; 9. Complications of transplanted cornea; 10. Post-traumatic corneal scarring; OR 11. Pterygium or corneal ectasia that cause visual impairment. B. Sensorimotor Examination is covered when considered medically necessary for ANY of the following conditions: 1. Diplopia; 2. Exotropia; 3. Esotropia; 4. Hypertropia; OR 5. Paralytic strabismus. C. Fitting of Contact Lens is covered for the treatment of disease for ANY of the following conditions: 1. Bullous keratopathy; 2. Dry eyes; 3. Corneal ulcers; 4. Corneal abrasions; 5. Keratitis; 6. Corneal edema; 7. Descemetocele; 8. Corneal ectasis; 9. Mooren's ulcer; 10. Anterior corneal dystrophy; OR 11. Neurotrophic keratoconjunctivitis. 12. The initial fitting of gas permeable contact lens is indicated for the management ofkeratoconus. D. Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is covered to diagnose early glaucoma and monitor glaucoma treatment in members with mild to moderate damage. Glaucomatous damage is defined by ONE of the following criteria: 1. Glaucoma-suspect or mild glaucomatous damage (mild stage glaucoma): a. Anomalous appearing optic nerve; b. Intraocular pressure greater than 22 mmHg as measured by applanation; c. Symmetric or vertically elongated cup enlargement, neural rim intact, cup to disc ratio greater than 4.0; d. Focal optic disk notch; e. Optic disk hemorrhage or history of optic disk hemorrhage; f. Nasal step or small paracentral or arcuate scotoma; OR g. Mild constriction of visual field isopters. 2. Moderate glaucomatous damage (moderate stage glaucoma): a. Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio greater than 0.5, but less than 0.9; b. Definite focal notch with thinning of the neural rim; OR c. Definite glaucomatous visual field defect, e.g., arcuate or paracentral scotoma, nasal step, pencil wedge, or constriction of isopters. 3. Advanced glaucomatous damage (severe stage glaucoma): a. Severe generalized constriction of isopters (i.e., Goldmann 14e greater than 10 degrees of fixation); b. Absolute visual field defects within 10 degrees of fixation; c. Severe generalized reduction of retinal sensitivity; d. Loss of central visual acuity, with temporal isla

FAQs

What are the coverage criteria for Computerized Corneal Topography?

It is covered when medically necessary and when indications apply, such as pre-operative evaluation for irregular astigmatism with cataract surgery, monocular diplopia, keratoconus diagnosis, specified post-surgical or post-traumatic astigmatism, corneal dystrophies, transplant complications, corneal scarring, and pterygium or corneal ectasia causing visual impairment.

When is SCODI (Scanning Computerized Ophthalmic Diagnostic Imaging) covered?

SCODI is covered to diagnose early glaucoma and monitor treatment for members with mild to moderate damage. Glaucomatous damage must meet defined criteria across mild, moderate, or advanced stages, with advanced cases listed as non-covered for SCODI.

What situations are explicitly not covered under this policy?

Computerized corneal topography is not covered for routine follow-up, repeat testing without a vision change tied to listed conditions, on the same date as keratoplasty, or for screening purposes. SCODI is not covered to further validate diagnoses already confirmed, for advanced glaucomatous damage (visual fields are required instead), or when performed without a stated Medicaid indication.

Oct 23, 2026

Uploaded by Logic