This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
NC Medicaid has amended Clinical Coverage Policy 1T-2, Special Ophthalmological Services. This update includes Current Procedural Terminology (CPT) code 65778, Placement of amniotic membrane on the ocular surface, without sutures, which was approved for coverage July 1, 2025. CPT code 65778 may be billed by both Optometrists and Ophthalmologists.
Claim denials after July 1, 2025, for CPT code 65778 may be resubmitted.
1T-2 policy updates also include the following additions:
- Bullous keratopathy as an indication for computerized corneal topography
- Hypotropia as an indication for sensorimotor exam;
- SCODI is to be covered to diagnose and monitor glaucoma treatment; evaluate disorders of the cornea, iris and ciliary body; evaluate and treat optic nerve, retinal or macular disease; monitor for irreversible retinal toxicity in a beneficiary on long-term chloroquine or hydroxychloroquine therapy;
- Coverage for placement of an amniotic membrane on the ocular surface without sutures is used to treat damaged or diseased corneal tissue;
- Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following: when there is no change in the treatment plan; no new symptoms are present; or the previous result was reliable; and
- Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.
The tables “ICD-10 diagnosis codes to support medical necessity for SCODI procedures” and “ICD-10 diagnosis codes to support medical necessity for fundus photography procedures” were deleted.
For the full policy details, refer to the updated clinical coverage policy on the NC Medicaid Program Specific Clinical Coverage Policies webpage.
Contact
NC Medicaid Contact Center: 888-245-0179