Clinical Policies

Adjacent Tissue Transfer Grafts involving Eyelid (CP.VP.01)
Age Related Macular Degeneration (CP.VP.02)
Amblyopia (CP.VP.03)
Amniotic Membrane Placement on the Ocular Surface (CP.VP.04)
Anterior Segment Photography with Fluorescein Angiography (CP.VP.67)
Aqueous Shunt (CP.VP.05)
Blepharoplasty Ptosis Repair and Canthoplasty (CP.VP.07)
Canthotomy (CP.VP.76)
Cataract Extraction (CP.VP.08)
CCI Bypass Modifiers (CP.VP.73)
Chemodenervation (CP.VP.10)
Complex Cataract Extraction (CP.VP.12)
Consultations (CP.VP.15)
Corneal Hysteresis (CP.VP.17)
Corneal Pachymetry (CP.VP.16)
Corneal Topography (CP.VP.18)
Dark Adaption and Color Vision Examinations (CP.VP.23)
Destruction of Extensive or Progressive Retinopathy (CP.VP.19)
Destruction of Localized Lesion of Choroid (CP.VP.20)
Destruction of Localized Lesion of the Retina (CP.VP.21)
Early and Periodic Screening Diagnosis and Treatment (CP.VP.27)
Ectropion Entropion Repair (CP.VP.25)
Electroretinography (CP.VP.86)
Examination Guidelines for Diabetic Patients (CP.VP.22)
Extended Ophthalmoscopy (CP.VP.26)
External Ocular Photography (CP.VP.43)
Eye Examination under General Anesthesia (CP.VP.81)
Eyelid Reanimation (CP.VP.78)
Fluorescein Angiography (CP.VP.28)
​Fundus Photography (CP.VP.29)
Glaucoma (CP.VP.30)
Glaucoma Screening (CP.VP.77)
Gonioscopy (CP.VP.31)
Guidelines for Dilation Protocol during Examination of the Eye (CP.VP.24)
Indocyanine Green (ICG) (CP.VP.32)
Infracture of the Inferior Turbinate (CP.VP.33)
Intraocular Lens Implants (CP.VP.82)
Iris Coloboma (CP.VP.34)
Keratoplasty (CP.VP.36)
Laser Iridotomy and Iridectomy (CP.VP.37)
Laser Trabeculoplasty (CP.VP.38)
Low Vision Evaluations and Aids (CP.VP.71)
Medical Eye Examinations (CP.VP.41)
Medically Necessary Optical Hardware (CP.VP.06)
New Technologies and New Uses of Existing Technologies (CP.VP.42)
Ocular Prosthesis (CP.VP.44)
Ocular Surface Reconstruction (CP.VP.80)
Ophthalmic B scans (CP.VP.68)
Ophthalmic Biometry (CP.VP.45)
Optic Nerve Decompression Surgery (CP.VP.09)
Pediatric Eye Examinations (CP.VP.47)
Photodynamic and Intravitreal Therapies and Pharmaceuticals (CP.VP.40)
Preventive (Routine) Eye Examination (CP.VP.13) (Attachment A)
Probing and Closure of the Lacrimal Duct System (CP.VP.11)
Prophylaxis of Retinal Detachment (CP.VP.53)
Recurrent Corneal Erosion and Phototherapeutic Keratectomy (CP.VP.49)
Refraction (CP.VP.35)
Refractive Surgery (CP.VP.52)
Repair of Retinal Detachment (CP.VP.54)
Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14)
Secondary Intraocular Lens (IOL) (CP.VP.48)
Sensorimotor Examination (CP.VP.55)
Serial Tonometry (CP.VP.74)
Specular Microscopy (CP.VP.66)
Surgical Excision of Eyelid Lesions (CP.VP.75)
Surgical Strabismus Repair (CP.VP.57)
Telehealth Services (CP.VP.84)
Teleretinal Screening for Diabetic Retinopathy (CP.VP.88)
Trabeculectomy Ab Externo (CP.VP.61)
Treatment of Meibomian Gland Dysfunction (CP.VP.85)
Visual Evoked Potential (CP.VP.70)
Visual Field Testing (CP.VP.63)
Visual Therapy (CP.VP.46)
Vitrectomy (CP.VP.64)
Voretigene Neparvovec%20rzyl (Luxturna) (CP.VP.87)
Yttrium Aluminium Garnet (YAG) Laser Capsulotomy (CP.VP.65)