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Ophthalmic Diagnostic Imaging Policy Revision: Effective September 1, 2026
Effective date
Sep 1, 2026
Identified
Aug 26, 2026
Summary
Sunflower Health Plan (Centene/Envolve) revised its Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) policy effective September 1, 2026, clarifying medical necessity indications for anterior segment, optic nerve, and posterior retinal SCODI imaging. The policy explicitly excludes coverage for advanced glaucomatous damage and screening for glaucoma, requiring billing teams to implement denial protocols for these non-covered indications.
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What to do
Action · 4 steps
01Before August 31, 2026: Billing team must update claim scrubbing rules and denial protocols in the billing system to automatically flag and deny SCODI claims (including OCT angiography) when coded for advanced glaucomatous damage or glaucoma screening.
02Update provider encounter documentation templates and prior authorization forms to specify covered SCODI indications (anterior segment, optic nerve, posterior retinal) versus non-covered uses.
03Communicate policy changes to ophthalmology and optometry providers to ensure claims are submitted only for medically necessary indications.
04Implement denial reason codes specific to non-covered SCODI indications to streamline appeals and member communication.
If missed: Failure to implement these changes will result in incorrectly paid claims that may require recovery.
Original notice
Ophthalmic Diagnostic Imaging Policy Revision: Effective September 1, 2026
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