Academy Derails Proposed Multi-State Non-Coverage of Critical Diagnostic Tools

Two major Medicare carriers are reversing course after the Academy objected to a plan to deny in multiple states access to effective diagnostic tools used for retina, glaucoma and other eye care patients. The carriers, Novitas Solutions, Inc., and Palmetto GBA, in March proposed limiting access to the computer-based diagnostic method of optical coherence tomography. After we reiterated the Academy’s belief in the effectiveness of OCT for advanced glaucoma, the carrier announced it would not make substantial changes to its existing coverage determination. 

This issue threatened to affect patients in Arkansas, Colorado, Delaware, Louisiana, Maryland, Mississippi, New Mexico, New Jersey, North Carolina, Oklahoma, Pennsylvania, South Carolina, Texas, Virginia, West Virginia and the Washington D.C. metro area. 

Novitas will mostly abandon its proposal, but the carrier says it is still making minor changes to its coverage of anterior segment OCT. Novitas will still cover the use of this tool, but with some restrictions. Palmetto intends to include coverage for AS-OCT to evaluate the anterior chamber angle in patients who are unable to undergo gonioscopy. 

The Academy worked with the American Glaucoma Society to halt a tangential, but equally problematic issue with this proposal: erroneous descriptions of mild, moderate and severe glaucoma. The decision to shun widely used definitions for glaucoma would have resulted in inaccurate coding.