Aetna modified CPB 0344 for optic nerve and retinal imaging, effective January 31, 2026. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its optic nerve and retinal imaging coverage policy under CPB 0344 Aetna system. The changes affect CPT codes 92133, 92134, and 92137 for scanning and optical coherence tomography (OCT) imaging, along with Category III codes 0604T, 0605T, and 0606T for remote patient-initiated OCT. If your practice bills retinal or optic nerve imaging for Aetna members, this update changes what gets paid — and what triggers a claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Optic Nerve and Retinal Imaging Methods |
| Policy Code | CPB 0344 |
| Change Type | Modified |
| Effective Date | January 31, 2026 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Optometry, Neuro-Ophthalmology, Retinal Surgery |
| Key Action | Audit charge capture for 92133, 92134, 92137, and OCTA billing before January 31, 2026 |
Aetna Optic Nerve and Retinal Imaging Coverage Criteria and Medical Necessity Requirements 2026
The Aetna optic nerve and retinal imaging coverage policy under CPB 0344 ties reimbursement to specific diagnoses. Medical necessity is established for a defined list of conditions — not for general screening or clinician preference.
Covered imaging methods include confocal laser scanning ophthalmoscopy, nerve fiber layer testing with confocal laser scanning tomography and polarimetry, optical coherence tomography (OCT) via CPT 92133 and 92134, and stereophotogrammetry. CPT 92137 covers OCT of the posterior segment. These four methods are the accepted standard under this coverage policy.
For glaucoma, Aetna draws a hard line: optic nerve imaging more than once per year is not medically necessary. This is a frequent trigger for claim denial in high-volume glaucoma practices. If you're billing 92133 twice in a calendar year for glaucoma, expect a denial unless there's a documented clinical reason tied to a different covered indication.
OCTA vs. Fluorescein Angiography — The Coverage Trade-Off
Optical coherence tomography angiography (OCTA) gets covered as a medically necessary alternative to fluorescein angiography (FA, billed under CPT 92235 or 92242). The key word is "alternative." Aetna does not cover both OCTA and FA for the same indication. Bill one or the other — not both.
The same rule applies to OCT and OCTA. Performing both for the same indication on the same date is not medically necessary under this policy. If your workflow routinely runs OCT and OCTA together, your billing team needs to flag this now.
OCTA coverage applies to three categories. First, diagnosis of chorioretinal vascular abnormalities including age-related macular degeneration (AMD), choroidal neovascularization, and non-infectious vasculitis. Second, evaluation of acute exudative inflammation such as toxoplasmosis and optic disc edema, diabetic retinopathy, and intra-ocular tumors. Third, monitoring treatment for conditions amenable to laser photocoagulation and anti-VEGF therapy, including macular edema.
Drug Toxicity Screening — Baseline and Annual Rules
Chloroquine (Aralen), hydroxychloroquine (Plaquenil), and vigabatrin (Sabril) each require a baseline study before therapy begins. Annual screening after five years of use — or sooner with unusual risk factors — is also covered. Document the therapy start date and screening rationale clearly in the chart.
For ethambutol (Myambutol), ezogabine (Potiga), ponatinib (Iclusig), and siponimod (Mayzent), the policy covers annual screening after five years of use, or sooner with unusual risk factors. The policy does not specify a baseline-before-therapy requirement for these drugs. Without clear documentation of the screening rationale, prior authorization requests and claims both get harder to defend.
Aetna Optic Nerve and Retinal Imaging Exclusions and Non-Covered Indications
Aetna's experimental and investigational list under CPB 0344 is longer than most billing teams realize. Several conditions that clinicians might reasonably image are explicitly excluded from coverage.
Remote patient-initiated OCT — billed under 0604T, 0605T, and 0606T — is considered experimental, investigational, or unproven. If your practice uses a patient-facing OCT device that transmits images to a remote surveillance center, don't bill these codes expecting reimbursement from Aetna. They won't pay it.
Fingolimod (Gilenya) monitoring is also excluded. This catches some neurology and MS practices off guard, since fingolimod requires ocular monitoring per prescribing guidelines. Aetna's position is that retinal imaging for fingolimod monitoring is not medically necessary under this policy. Document your rationale carefully and review your options with your compliance officer if you're seeing these claims denied.
Other explicitly excluded indications include:
| # | Excluded Procedure |
|---|---|
| 1 | Retinal imaging as a biomarker for peripheral artery disease |
| 2 | Cataracts and posterior capsule opacification |
| 3 | Dry eye diseases |
| 4 | Neurodegeneration pattern evaluation for intra-cranial tumors |
| 5 | Parinaud oculoglandular syndrome (cat scratch disease) |
| 6 | Schizophrenia spectrum disorders |
| 7 | Visual snow syndrome |
| 8 | Imaging following IOL exchange for IOL dislocation |
| 9 | Retinal imaging as a biomarker for neurodegeneration in frontotemporal degeneration, multiple sclerosis, or optic neuritis |
| 10 | Ocular histoplasmosis |
| 11 | Routine screening of asymptomatic persons for glaucoma or other retinal diseases |
That last one is important. Routine asymptomatic glaucoma screening — even in a high-risk patient — is not covered. There must be a diagnosis or a documented clinical indication tied to one of the covered conditions.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Age-related macular degeneration | Covered | 92133, 92134, 92137 | OCTA covered as FA alternative |
| Cystoid macular edema (post-cataract) | Covered | 92134, 92137 | Document post-surgical context |
| Diabetic retinopathy | Covered | 92133, 92134, 92137 | OCTA covered for evaluation |
| Dysthyroid optic neuropathy | Covered | 92133 | |
| Epiretinal membrane | Covered | 92134, 92137 | |
| Ethambutol-induced optic neuropathy | Covered | 92133 | Annual screening after 5 years of use |
| Glaucoma | Covered | 92133 | Once per year maximum |
| Glaucoma suspects | Covered | 92133 | |
| Macular edema | Covered | 92134, 92137 | OCTA covered for treatment monitoring |
| Macular hole | Covered | 92134, 92137 | |
| Non-arteritic anterior ischemic optic neuropathy | Covered | 92133 | |
| Posterior vitreous detachment | Covered | 92134, 92137 | |
| Pseudotumor cerebri | Covered | 92133 | |
| Chloroquine / hydroxychloroquine toxicity screening | Covered | 92133, 92134 | Baseline before therapy; annual after 5 years |
| Vigabatrin toxicity screening | Covered | 92133, 92134 | Baseline before therapy; annual after 5 years |
| Ezogabine, ponatinib, siponimod toxicity screening | Covered | 92133, 92134 | Annual screening after 5 years of use |
| Sudden onset vitreous hemorrhage | Covered | 92134, 92137 | |
| Vitreomacular traction / adhesion | Covered | 92134, 92137 | |
| Vogt-Koyanagi-Harada disease | Covered | 92134, 92137 | To quantify subretinal fluid and monitor treatment |
| Choroidal neovascularization | Covered | 92137 | OCTA covered as FA alternative |
| Non-infectious vasculitis | Covered | 92137 | OCTA covered as FA alternative |
| Intra-ocular tumors | Covered | 92134 | OCTA for evaluation |
| Remote patient-initiated OCT | Experimental | 0604T, 0605T, 0606T | Not covered; expect claim denial |
| Retinal polarization scan (screening) | Experimental | 0469T | Not covered for asymptomatic screening |
| Fingolimod (Gilenya) monitoring | Experimental | 92133, 92134 | Explicitly excluded |
| Routine asymptomatic glaucoma/retinal screening | Not Covered | 92133, 92134 | No diagnosis = no coverage |
| Dry eye disease | Experimental | — | Not covered |
| Cataracts / posterior capsule opacification | Experimental | — | Not covered |
| MS / frontotemporal degeneration neurodegeneration | Experimental | — | Biomarker use not covered |
| Ocular histoplasmosis | Experimental | — | Not covered |
| Visual snow syndrome | Experimental | — | Not covered |
| Schizophrenia spectrum disorders | Experimental | — | Not covered |
Aetna Optic Nerve and Retinal Imaging Billing Guidelines and Action Items 2026
These are direct steps your billing team should take before or immediately after the January 31, 2026 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your OCTA and FA billing combinations. Pull claims from the past 90 days where 92137 and 92235 or 92242 appear together for the same patient encounter. If you're billing both OCTA and FA for the same indication, that's a known denial trigger under this policy. Fix your charge capture rules to prevent same-indication dual billing. |
| 2 | Set a frequency edit for glaucoma imaging. Configure your billing system to flag any second claim for CPT 92133 within a 12-month period for a glaucoma diagnosis. Aetna is explicit: more than once per year is not medically necessary. A hard stop in your charge capture saves the denial and the appeal work. |
| 3 | Document drug toxicity baselines before therapy starts. For any patient starting chloroquine, hydroxychloroquine, or vigabatrin, the baseline retinal imaging study must be performed and documented before the first dose. Retroactive documentation won't support a claim after the fact. Build a workflow that triggers the imaging order at the time of the medication order. |
| 4 | Stop billing 0604T, 0605T, and 0606T for Aetna patients. Remote patient-initiated OCT is experimental under this policy. These Category III codes will not be reimbursed. If you've been billing them, conduct a lookback for the past six months and assess your exposure. If the volume is significant, loop in your compliance officer before the effective date. |
| 5 | Check your ICD-10 codes against the covered indication list. Diagnosis codes for excluded conditions such as dry eye or cataracts will not support a covered claim under CPB 0344. Your diagnosis codes must map to a covered indication. Train your coding staff on the specific exclusions — particularly the neurological conditions that seem clinically appropriate but are explicitly experimental under CPB 0344. |
| 6 | Review fingolimod patient panels with your neurology or MS colleagues. If you're imaging patients on fingolimod and billing to Aetna, those claims will deny. This isn't a gray area — it's a named exclusion. You may need to discuss medical necessity documentation with the prescribing physician and review your options with your compliance officer. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Optic Nerve and Retinal Imaging Under CPB 0344
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 92133 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; optic nerve |
| 92134 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; retina |
| 92137 | CPT | Computerized ophthalmic diagnostic imaging (e.g., optical coherence tomography [OCT]), posterior segment, with interpretation and report |
Other CPT Codes Related to CPB 0344
These codes appear in the policy context — primarily as alternatives to or comparators with covered imaging methods.
| Code | Type | Description |
|---|---|---|
| 92235 | CPT | Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral |
| 92242 | CPT | Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter, with interpretation and report |
| 92287 | CPT | Anterior segment imaging with interpretation and report; with fluorescein angiography |
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0469T | CPT | Retinal polarization scan, ocular screening with on-site automated results, bilateral | Experimental for asymptomatic screening |
| 0604T | CPT | Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, with report; initial | Experimental — patient-initiated remote OCT not covered |
| 0605T | CPT | OCT of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, with report; each additional | Experimental — patient-initiated remote OCT not covered |
| 0606T | CPT | OCT of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, with report; technical support and data review | Experimental — patient-initiated remote OCT not covered |
Key ICD-10-CM Diagnosis Codes
The full policy lists 511 ICD-10-CM codes. The table below covers the highest-frequency billing scenarios under CPB 0344.
| Code | Description |
|---|---|
| A28.1 | Cat-scratch disease (Parinaud oculoglandular syndrome — excluded) |
| B39.4 | Histoplasma capsulati infection, unspecified (ocular histoplasmosis — excluded) |
| B50.0–B54 | Malaria |
| B58.01 | Toxoplasma chorioretinitis |
| B58.0–B58.9 | Toxoplasmosis (various manifestations) |
| C69.0–C69.9 | Malignant neoplasm of eye and adnexa |
| C69.20–C69.29 | Malignant neoplasm of the retina and choroid |
For the complete ICD-10 code list tied to this policy, use the full CPB 0344 reference at Aetna or access the full code set via PayerPolicy.
Get the Full Picture for CPT 92133
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.