Diagnosis: retinal lesion bilaterally

Treatment: CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side

The insurer is denied coverage for CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side.

The denial is overturned.

This male patient has a history of diabetes, type ll with ocular complications including vitreous hemorrhage in the right eye (OD), proliferative diabetic retinopathy (PDR) in both eyes (OU), clinically significant macular edema (CSME) OU, pseudophakia OU, chronic neurovascular glaucoma (NVG) OU, diabetes, type ll with ocular complications.

The American Academy of Ophthalmology indicates symptomatic retinal breaks constitute a category of retinal breaks for which intervention is generally indicated. These are characterized by the perception of increased flashers or floaters that usually occur due to increased vitreoretinal traction exerted during an acute posterior vitreous detachment. Retinal breaks with persistent vitreous traction at the edge yield retinal detachments 50% of the time, and should be treated with immediate laser retinopexy, which reduces the risk of retinal detachment to less than 5%. The patient had complaints of blurred vision left greater than right, and flashes bilaterally. Examination noted clear vitreous bilaterally, neovascular retina on the right, sclerotic vessels on the left, scattered dot/blot hemorrhages in the macula bilaterally with no edema. There was preretinal hemorrhage on the right. The patient has proliferative retinopathy with retinal hemorrhages. This is an indication for laser. As such, the request for CPT code 67210 is medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side is overturned. The medical necessity is substantiated.