Ophthalmic Angiography (Fluorescein and Indocyanine Green)

LCD Information Document Information Source LCD ID N/A LCD ID L34175 Original ICD-9 LCD ID Not Applicable LCD Title Ophthalmic Angiography (Fluorescein and Indocyanine Green) Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 05/28/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Current Dental Terminology © 2025 American Dental Association. All rights reserved. Copyright © 2026, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at ub04@aha.org or 312‐422‐3366. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Issue Issue Description Limited coverage as outlined in coverage and indication section. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). Coverage Indications, Limitations, and/or Medical Necessity Abstract: FluoresceinFluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence on 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 GreenIndocyanine green 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, Indocyanine Green 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. Indocyanine green angiography (ICG) is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration). It is also useful in the evalution of feeder vessels, choroidal leakages in the late phase, and ruptures of the pigment epithelium. Indications: FluoresceinFluorescein angiography with interpretation is medically necessary as an adjunct to the diagnosis of chorioretinal vascular abnormalities especially relating to choroid neovascularization, noninfective vasculitis, and age related macular degeneration. 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 GreenIndocyanine green angiography (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: FluoresceinStudies 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 Age related Macular Degeneration (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 GreenIndocyanine green 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. Indocyanine green 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. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: Fluorescein Fluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence on 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 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, Indocyanine Green 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. Indocyanine green angiography (ICG) is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration). It is also useful in the evalution 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 age related macular degeneration. 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 Indocyanine green angiography (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 Age related Macular Degeneration (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 Indocyanine green 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. Indocyanine green 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.