Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 15102 | CGS Administrators, LLC | MAC - Part B | KY |
| 15202 | CGS Administrators, LLC | MAC - Part B | OH |
| 15101 | CGS Administrators, LLC | MAC - Part A | KY |
| 15201 | CGS Administrators, LLC | MAC - Part A | OH |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57069 (Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57069: Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) (Billing and Coding, effective 2026-05-28)
- Covered ICD-10-CM codes
- 595
- 3 groups
- Non-covered ICD-10-CM codes
- 206
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A18.53 | — |
| B20 | Human immunodeficiency virus [HIV] disease |
| B58.01 | — |
| C69.21 | — |
| C69.22 | — |
| C69.31 | — |
| C69.32 | — |
| D18.09 | — |
| D31.21 | — |
| D31.22 | — |
| D31.31 | — |
| D31.32 | — |
| D57.01 | — |
| D57.02 | — |
| D57.03 | — |
| D57.04 | — |
| D57.1 | — |
| D57.20 | — |
| D57.211 | — |
| D57.212 | — |
| D57.213 | — |
| D57.214 | — |
| D57.80 | — |
| D57.811 | — |
Procedure codes: 92235, 92240.
Coverage indications, limitations and medical necessity
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.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2026-05-28
- Last reviewed by the contractor
- 2026-05-15
- MCD version
- 32
- Derived from
- L31882
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the CGS Administrators, LLC hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L34175 cover?
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 full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34175 apply to?
CGS Administrators, LLC applies it to Medicare claims in KY, OH. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34175?
The companion billing and coding article A57069 lists 595 ICD-10-CM codes in 3 groups that support medical necessity and 206 that do not; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34175?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.