Angiography with fluorescein and indocyanine green

Frequently asked questions

How long does the test last?

The fluorescein angiography test lasts about 10 minutes, whereas the Indocyanine Green Angiography typically lasts around 40 minutes. However, the overall time a patient spends at the center, from arrival to departure, is approximately 1 hour.

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Should the test be done on an empty stomach?

No fasting is required before undergoing the test. You can have a regular breakfast but avoid excessive eating.

Should I come accompanied?

It is crucial to be accompanied during the test, as your vision will be temporarily blurred. Pupil dilation will occur, making it unsafe for you to drive afterward.

Are there any side effects?

The side effects observed from the procedure typically stem from pupil dilation. These may include glare and blurry vision. During the test, various lights and flashes from the apparatus may cause mild discomfort, and occasionally, patients report nausea or sensation of warmth. In rare instances, more intense reactions may be experienced.

Post-test, blurred vision can persist for a few hours due to the dilating drops. Some patients might also notice changes in their skin color or urine colors, as the dye passes through the system and is expelled in urine.

What happens if I have an unexpected reaction to the dye?

Our medical staff is trained in resuscitation and available to handle any emergencies that may arise.

How long do the side effects last after the test?

Glare can persist for as long as the effects of the dilating drops, usually around 4 hours. Changes in urine color may last from 1 to 3 days, depending on the patient's renal function.

What are the advantages of having the angiography at the ICR?

The ICR boasts the most advanced technology available. The adaptable and versatile tools we employ focus on the patient's specific condition, allowing us to capture detailed images of the eye's internal layers. Furthermore, we can combine angiography with other informative tests, such as optical coherence tomography (OCT).

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Table Of Contents

Policy

Applicable CPT / HCPCS / ICD-10 Codes

Background

References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses indocyanine green angiography.

1. Medical Necessity

   Aetna considers the following interventions medically necessary: 

   1. Indocyanine green angiography used as a complementary tool to fluorescein angiography for diagnosing and treating any of the following conditions:

      1. Acute posterior multi-focal placoid pigment epitheliopathy; or
      2. Evaluation of choroidal hemangioma; or
      3. Exudative senile macular degeneration; or
      4. Hemorrhagic detachment of retinal pigment epithelium; or
      5. Monitoring birdshot chorioretinitis; or
      6. Monitoring of foveomacular vitelliform dystrophy (Best's disease); or
      7. Multiple evanescent white dot syndrome (MEWDS); or
      8. Retinal hemorrhage; or
      9. Retinal neovascularization; or
      10. Serous detachment of retinal pigment epithelium.

      Note: Documentation in the patient's medical records must indicate one of the following:

      1. Evidence of ill-defined sub-retinal neovascular membrane or suspicious membrane on prior fluorescein angiography; or
      2. Presence of sub-retinal hemorrhage or hemorrhagic retinal pigment epithelium. No previous fluorescein angiography is necessary; or
      3. Retinal pigment epithelium does not show sub-retinal neovascular membrane on current fluorescein angiography.

      The physician must provide documentation to justify the frequency and necessity of this procedure.

   2. The intra-operative use of indocyanine green angiography for intracranial aneurysm surgery;
   3. Near-infrared angiography with indocyanine green (e.g., Spy Elite System) for breast reconstruction surgery. Note: Intraoperative imaging of tissue perfusion is considered critical and is not billed separately;
   4. Utilization of indocyanine green for sentinel lymph node mapping in cases of cervical cancer, endometrial cancer, and endometrial intraepithelial neoplasia.

2. Experimental, Investigational, or Unproven

   The following interventions are regarded as experimental, investigational, or unproven due to insufficient evidence of efficacy:

   1. Indocyanine green angiography performed in the following scenarios (this list is not exhaustive) because the safety and effectiveness of these practices have not been confirmed:

      1. Intra-operative anatomical dissection during robot-assisted radical prostatectomy
      2. Assessment of anastomotic leak/perfusion during or post esophagectomy
      3. Evaluation of anastomotic leakage/perfusion in colorectal surgery
      4. Investigation of anastomotic perfusion after bowel resection for recto-sigmoid endometriosis
      5. Examination of anastomotic stenosis in reconstructed superior mesenteric artery aneurysm
      6. Evaluation of chorioretinal scars
      7. Examination of complaints regarding vision loss
      8. Assessment of perfusion in the supra-clavicular artery island flap during head and neck reconstruction
      9. Evaluation of residual parathyroid gland functionality and prediction of post-operative hypocalcemia risk after total thyroidectomy
      10. Follow-up on branch retinal vein occlusion status after treatment with bevacizumab
      11. Guidance during redo ileocolic resection for Crohn's disease
      12. Identification of the superficial temporal artery and vein in forehead flaps for facial reconstruction
      13. Indocyanine green angiography-assisted internal limiting membrane peeling in macular hole surgeries
      14. Indocyanine green fluorescence imaging in bariatric surgery
      15. Intra-operative evaluation for flap perfusion during skull base reconstruction
      16. Intra-operative monitoring during pancreas stump perfusion assessment during pancreaticoduodenectomy
      17. Intra-operative application to reduce the incidence of anastomotic leakage after rectal cancer surgeries
      18. Intra-operative usage in microsurgical sub-inguinal varicocelectomy
      19. Intra-operative measures to lower anastomotic leakage due to colorectal surgery
      20. Predictions regarding post-operative thrombosis in the internal jugular vein
      21. Prediction of surgical complications in ventral hernia repair
      22. Preventing surgical morbidity (e.g., anastomotic leakage, chylothorax, and graft necrosis) during esophagectomy;

   2. Use of indocyanine green in sentinel lymph node mapping for other cancers (e.g., bladder, breast, colon, kidney, melanoma, ovary, penis, prostate, and stomach; not comprehensive);

CPT Codes / HCPCS Codes / ICD-10 Codes

CPT codes covered if selection criteria are met:

Indocyanine-green angiography (includes multi-frame imaging) with interpretation and report

Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral

Other CPT codes related to the CPB:

Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

     neurovascular pedicle

Free muscle or myocutaneous flap with microvascular anastomosis

Free skin flap with microvascular anastomosis

Free fascial flap with microvascular anastomosis

Intravenous injection of agent (for example, fluorescein) to test vascular flow in flap or graft

Entire or majority of forehead reconstruction with grafts (allograft or prosthetic material)

Entire or majority of forehead reconstruction with autograft (includes obtaining grafts)

Direct repair of both aneurysms, pseudoaneurysms, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysms, pseudoaneurysms, and associated occlusive disease, hepatic, celiac, renal, or mesenteric arteries

Direct repair of both aneurysms, pseudoaneurysms, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysms, hepatic, celiac, renal, or mesenteric arteries

Intra-operative identification of sentinel lymph node(s) involves the injection of non-radioactive dye, when performed (listed separately in addition to the main procedure code)

Other HCPCS codes related to the CPB:

C - Injection, bevacizumab, 0.25 mg

J - Injection, bevacizumab, 10 mg

Q - Injection, bevacizumab-awwb, biosimilars (mvasi), 10 mg

Q - Injection, bevacizumab-bvzr, biosimilars (Zirabev), 10 mg

Q - Injection, bevacizumab-maly, biosimilars (alymsys), 10 mg

Q - Injection, bevacizumab-adcd (vegzelma), biosimilars, 10 mg

ICD-10 codes covered if selection criteria are met:

C53.0 - C53.9 Malignant neoplasm of cervix uteri

C54.1 Malignant neoplasm of endometrium

C69.30 - C69.32 Malignant neoplasm of choroid [not covered for choroidal melanoma]

D06.0 - D06.9 Carcinoma in situ of cervix uteri

D07.0 Carcinoma in situ of endometrium

D18.09 Hemangioma of other sites [choroidal]

H30.141 - H30.149 Acute posterior multifocal placoid pigment epitheliopathy

H30.891 & H30.899 Other chorioretinal inflammations [birdshot chorioretinitis] [multiple evanescent white dot syndrome (MEWDS)]

H30.90 - H30.93 Unspecified chorioretinal inflammation

H31.8 Other specified disorders of choroid

H35.051 - H35.059 Retinal neovascularization, unspecified

H35.09 Other intraretinal microvascular abnormalities

H35. - H35. Exudative age-related macular degeneration

H35.54 Dystrophies primarily involving retinal pigment epithelium

H35.60 - H35.63 Retinal hemorrhage [subretinal hemorrhage or hemorrhagic retinal pigment epithelium]

H35.711 - H35.719 Central serous chorioretinopathy

H35.721 - H35.729 Serous detachment of retinal pigment epithelium

H35.731 - H35.739 Hemorrhagic detachment of retinal pigment epithelium

N85.02 Endometrial intraepithelial neoplasia [EIN]

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

C16.0 - C16.9 Malignant neoplasm of stomach

C18.0 - C18.9 Malignant neoplasm of colon

C43.0 - C43.9 Malignant melanoma of skin

C50.011 - C50.929 Malignant neoplasm of breast

C56.1 - C56.9 Malignant neoplasm of ovary

C60.0 - C60.9 Malignant neoplasm of penis

C61 Malignant neoplasm of prostate

C64.1 - C64.9 Malignant neoplasm of kidney, except renal pelvis

C67.0 - C67.9 Malignant neoplasm of bladder

C70.0 Malignant neoplasm of cerebral meninges [parasagittal meningioma]

D00.2 Carcinoma in situ of stomach

D03.0 - D03.9 Melanoma in situ

D05.00 - D05.92 Carcinoma in situ of breast

D07.4 Carcinoma in situ of penis

D07.5 Carcinoma in situ of prostate

D09.0 Carcinoma in situ of bladder

D32.0 Benign neoplasm of cerebral meninges [parasagittal meningioma]

D86.0 - D86.9 Sarcoidosis

E08.311, E08. - E08., E08. - E08., E08. - E08., E08. - E08., E09.311, E09. - E09., E09. - E09., E09. - E09., E09. - E09., E10.311, E10. - E10., E10. - E10., E10. - E10., E10. - E10., E11.311, E11. - E11., E11. - E11., E11. - E11., E11. - E11., E13.311, E13. - E13., E13. - E13., E13. - E13., E13. - E13. Diabetes mellitus with diabetic retinopathy with macular edema

H15.001 - H15.129 Scleritis and episcleritis

H20.821 - H20.829 Vogt-Koyanagi syndrome

H30.811 - H30.819 Harada's disease

H31.001 ' H31.099 Chorioretinal scars

H31.101 - H31.109 Unspecified choroidal degeneration [hereditary drusen]

H33.101 - H33.199 Retinoschisis and retinal cysts

H34. ' H34. Tributary (branch) retinal vein occlusion [status post bevacizumab]

H35.361 - H35.369 Drusen (degenerative) of macula

H47.011 ' H47.019 Ischemic optic neuropathy [non-arteritic]

H47.321 - H47.329 Drusen of optic disc

H53.121 ' H53.129 Transient visual loss

H53.131 ' H53.139 Sudden visual loss

H54.3 Unqualified visual loss, both eyes

H54.60 ' H54.62 Unqualified visual loss, one eye

H54.7 Unspecified visual loss

H59.811 ' H59.819 Chorioretinal scars after surgery for detachment

I72.8 Aneurysm of other specified arteries [superior mesenteric artery]

I77.0 Arteriovenous fistula, acquired

I89.8 Other specified noninfective disorders of lymphatic vessels and lymph nodes [prevention of chylothorax]

K43.0 - K43.9 Ventral hernia

K50.00 - K50.919 Crohn's disease [regional enteritis]

K91.81 Other intraoperative complications of digestive system [anastomotic leakage in colorectal surgery] [prevention of surgical morbidity][prevention of anastomotic leakage after rectal cancer surgery]

K91.89 Other postprocedural complications and disorders of digestive system [anastomotic leakage in colorectal surgery] [prevention of surgical morbidity][prevention of anastomotic stenosis of superior mesenteric artery]

M35.2 Behcet's disease

Q27.30 ' Q27.39 Arteriovenous malformation (peripheral)

Q28.8 Other specified congenital malformations of circulatory system

T81.710A - T81.710S Complication of mesenteric artery following a procedure, not elsewhere classified [anastomotic stenosis]

Non-ophthalmic:

Other CPT codes related to the CPB:

Brest reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

Breast reconstruction with latissimus dorsi flap, without prosthetic implant

Breast reconstruction with free flap

Breast reconstruction with other technique

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

Intra-operative flap; convolution creation requiring identification and dissection of an anatomically named axial vessel

Intraoperative laser-assisted indocyanine green angiography for evaluating flap perfusion

Potentially, these data support the omission of side-specific lymphadenectomy in case of unsuccessful mapping.

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