CommercialCoverageMedium impact
Optic Nerve and Retinal Imaging Methods (CPB 0344, reviewed 2026-05-26)
Aetna·Ophthalmology, Optometry, Radiology·Radiology
Effective date
May 26, 2026
We identified it
Aug 12, 2026
Summary
Aetna updated CPB 0344 (Optic Nerve and Retinal Imaging Methods, effective 2026-05-26) to clarify coverage criteria for optic nerve and retinal imaging. Key changes include: (1) OCTA is now a medically necessary alternative to fluorescein angiography (FA) for specific AMD, CNV, vasculitis, diabetic retinopathy, and tumor indications; (2) performing both OCTA and FA for the same indication is not medically necessary; (3) OCTA for glaucoma diagnosis/monitoring remains experimental/investigational; (4) remote patient-initiated OCT capture (CPT 0604T, 0605T, 0606T) remains investigational; and (5) optic nerve imaging for glaucoma more than once per year is not medically necessary.
Action Required
By May 26, 2026, the billing team must: (1) Update billing software to enforce OCTA/FA bundling rules—deny claims when both OCTA AND FA are billed for the same indication on the same date of service; (2) Update the provider education materials and encounter templates to clarify that CPT 92137 (OCTA) is covered ONLY for AMD/CNV, non-infectious vasculitis, diabetic retinopathy, and intra-ocular tumor indications—not for glaucoma screening/monitoring; (3) Implement frequency limits in the billing system to flag and deny optic nerve imaging (CPT 92133) when billed more than once per year for glaucoma patients; (4) Continue to deny claims for remote OCT codes (0604T, 0605T, 0606T) as investigational—do not process these for any indication; (5) Communicate to ophthalmology and optometry providers the specific covered vs. non-covered OCTA scenarios to reduce claim rejections. Failure to implement these rules will result in payment denials and potential overpayment recovery demands.