0767 extended ophthalmoscopy medical clinical policy bulletins

Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna of 12

Extended Ophthalmoscopy

POLICY HISTORY

Last Review: 10/26/2021

Effective: 08/14/2009

Next Review: 08/25/2022

Review History

Definitions

Additional Information Clinical Policy Bulletin

Notes

Number: 0767

POLICY *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers extended ophthalmoscopy with a detailed retinal drawing

for evaluation of the posterior portion of the eye following routine

ophthalmoscopy medically necessary for any of the following indications:

Blunt injury to the eye or periorbital structures; or

Chorioretinitis, chorioretinal scars or choroidal degeneration,

dystrophies, hemorrhage and r upture, or detachment; or

Choroidal nevus being evaluated for malignant transformation; or

Degenerative disorders of the globe; or

Diabetic retinopathy (i.e., background retinopathy or proliferative

retinopathy retinal vascular occlusion, or separation of the retinal

layers); or

Disorders of the vitreous body (i.e., vitreous hemorrhage or

posterior vitreous detachment); or

High axial length myopia (-6.00 Diopters or less [toward -10.00 D]);

or

High-risk medication for retinopathy or optic neuropathy; or

HIV retinopathy; or

Macular degeneration; or

Malignant neoplasm of the retina or choroid; or

Metamorphopsia; or


Optic atrophy associated with a progressive and potentially

reversible cause (e.g., glaucoma); or

Penetrating wound to the orbit resulting in the retention of a

foreign body in the eye; or

Posterior scleritis; or

Retained (old) intra-ocular foreign body, either magnetic or non-

magnetic; or

Retinal defects without retinal detachment; or

Retinal detachment, with or without retinal defect; or

Retinal edema; or

Retinal hemorrhage, ischemia, exudates and deposits, hereditary

retinal dystrophies or peripheral retinal degeneration; or

Retinopathy of prematurity; or

Retinoschisis and retinal cysts; or

Sudden visual loss or transient visual loss; or

Suspected endophthalmitis as evidenced by severe pain, redness,

photophobia, and profound loss of vision; or

Symptoms suggestive of retinal defect; or

Systemic disorders associated with retinal pathology; or

Uncontrolled glaucoma or glaucoma suspect; or

Vogt-Koyanagi syndrome characterized by bilateral uveitis,

dysacousia, meningeal irritation, whitening of patches of hair

(poliosis), vitiligo, and retinal detachment.

Note: Extended ophthalmoscopy with a detailed retinal drawing for

evaluation of the posterior portion of the eye is considered not medically

necessary when initial routine ophthalmoscopy showed normal clinical

findings.

Aetnaconsiders repeat extended ophthalmoscopy medically necessary

when there is a change in signs, symptoms or condition for indications

(listed in the afore-mentioned policy section) that may progress.

Aetna considers extended ophthalmoscopy with a detailed retinal drawing

experimental and investigational for the following indications because its

effectiveness for these indications has not been established (not an all-

inclusive list):

Congenital hypertrophy of the retinal pigment epithelium


Juvenile xanthogranuloma

Monitoring of fingolimod (Gilenya) therapy

Monitoring methotrexate or tamoxifen therapy

Neurodegenerative disorders/diseases (e.g., Alzheimer's disease,

amyotrophic lateral sclerosis, Friedreich's ataxia, Huntington's

disease, Lewy body disease, multiple-system atrophy, Parkinson's

disease, and spinal muscular atrophy)

Noonan's syndrome

Ophthalmic artery aneurysm

Optic neuritis

Pseudotumor cerebri (orbital pseudotumor)

Retinal angioma

Screening for retinoblastoma

Sickle cell disease

Staphyloma posticum (posterior staphyloma).

BACKGROUND

Periodic comprehensive medical eye examinations are recommended in

adults without known ocular conditions or risk factors in an effort to detect

ocular disease and provide early treatment, thereby preserving visual

function. They are also performed periodically to evaluate new symptoms

and monitor patients with previously identified eye conditions or risk

factors. A comprehensive ophthalmologic evaluation may also be useful

in the initial diagnosis of a number of systemic diseases such as

hypertension, diabetes mellitus, and infectious diseases. A

comprehensive medical eye evaluation includes history, examination,

diagnosis, and initiation of management. Routine ophthalmoscopy is part

of general and special ophthalmologic services when indicated and is

useful for viewing the vitreous humor, retina, optic nerve, retinal veins and

arteries, and associated structures.

Extended ophthalmoscopy is a method of examining the posterior portion

of the eye when the level of examination requires a complete view of the

back of the eye and documentation is greater than that required during

routine ophthalmoscopy. Extended ophthalmoscopy may be indicated for

a wide range of posterior segment pathology. This inspection permits

visualization of the optic disk, arteries, veins, retina, choroid, and media.

It is usually performed with the pupil dilated, to ensure optimal

examination of the retina, utilizing indirect ophthalmoscopy. It may also

be performed using contact lens biomicroscopy and may use scleral


depression.

In all instances extended ophthalmoscopy must be medically necessary.

A serious retinal condition must exist, or be suspected, based on routine

ophthalmoscopy and require further detailed study. Extended

ophthalmoscopy must add information not available from the standard

evaluation services and/or information that will demonstrably affect the

treatment plan. It is not necessary, for example, to confirm information

already available by other means. When other ophthalmological tests

(e.g., fundus photography, fluorescein angiography, ultrasound, optical

coherence tomography, etc.) have been performed, extended

ophthalmoscopy is not necessary unless there is a reasonable medical

expectation that the multiple imaging services might provide additive

(non-duplicative) information.

The frequency for providing extended ophthalmoscopy depends upon the

medical necessity in each patient and this, of course, relates to the

diagnosis. A single drawing is necessary if it documents clinically

significant details that cannot be adequately or succinctly communicated

in writing alone. Sequential drawings may be necessary when they

describe a condition within the eye that is subject to change in extent,

appearance, or size, and where that change would directly affect the

management. Repeated extended ophthalmoscopy at each visit without

change in signs, symptoms or condition may be considered not medically

necessary.

APPENDIX

Documentation Requirements

Extended ophthalmoscopy includes a detailed retinal drawing, (disc,

macula or periphery) accompanied by an interpretation and plan. The

drawing should be anatomically specific to the patient and clearly labeled,

and be of sufficient size, usually no less than 2.5 inches in diameter. The

extensive scaled drawing should accurately represent normal, abnormal

and common findings such as lattice degeneration, hypertensive vascular

changes, proliferative diabetic retinopathy, retinal detachments, holes,

tears, or tumors. Where extended ophthalmoscopy is used in defining

optic nerve changes, ancillary drawings of cup to disc data elements

(size, depth, rim, vessels, coloration) are required to fulfill obligations for

documentation.


A standard approach to documenting retinal disease is to use a color-

coded scheme; however, such color coding is not a requirement. Where

color coding is not used, a description of the anatomy and pathology of

the fundus and periphery is required. There is more than one

professionally accepted color scheme. An example of one such color

scheme includes the color red for hemorrhage, flat retina and retinal hole;

blue for detached retina, retinal veins and outline of retinal tear; green for

vitreous pathology; brown for choroidal findings; black for changes to the

retinal pigment epithelium and blood vessels; yellow for retinal exudates;

and black outline filled with black lattice pattern for lattice degeneration of

attached retina.

CPT Codes/ HCPCS Codes/ICD-10 CodesInformation in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by “+”

Code Code Description

CPT codes covered if selection criteria are met:

92201 Ophthalmoscopy, extended; with retinal drawing and scleral

depression of peripheral retinal disease (e.g., for retinal tear,

retinal detachment, retinal tumor) with interpretation and report,

unilateral or bilateral

92202 with drawing of optic nerve or macula (e.g., for glaucoma,

macular pathology, tumor) with interpretation and report,

unilateral or bilateral

ICD-10 codes covered if selection criteria are met:


C69.20 -

C69.32

Malignant neoplasm of retina or choroid

D31.30 -

D31.32

Benign neoplasm of choroid [evaluation of choroidal nevus for malignant transformation]

E08.311,

E08.3211 -

E08.3219,

E08.3311 -

E08.3319,

E08.3411 -

E08.3419,

E08.3511 -

Diabetes mellitus due to underlying condition with ophthalmic

complications


E08.3559,

E09.311,

E09.3211 -

E09.3219,

E09.3311 -

E09.3319,

E09.3411 -

E09.3419,

E09.3511 -

E09.3559,

E10.311,

E10.3211 -

E10.3219,

E10.3311 -

E10.3319,

E10.3411 -

E10.3419,

E10.3511 -

E10.3559,

E11.311,

E11.3211 -

E11.3219,

E11.3311 -

E11.3319,

E11.3411 -


E11.3419,

E11.3511 -

E11.3559,

E13.311,

E13.3211 -

E13.3219,

E13.3311 -

E13.3319,

E13.3411 -

E13.3419,

E13.3511 -

E13.3559



E09.311 -

E09.39

Drug or chemical induced diabetes mellitus

E10.311 -

E10.39

E11.311 -

E11.39

E13.311 -

E13.39

Diabetes with ophthalmic complications, type I, type II or

unspecified type

G45.3 Amaurosis fugax

H05.50 -

H05.53

Retained (old) foreign body following penetrating w ound of orbit

H15.031 -

H15.039

Posterior scleritis

H16.241 -

H16.249

H21.331 -

H21.339

H33.121 -

H33.129

H44.001 -

H44.539

H44.811 -

H44.819

Disorders of the globe


H20.821 -

H20.829

Vogt-Koyanagi syndrome

H30.001 - H32

H35.33

Disorders of choroid and retina

H31.101 -

H31.129

H34.00 -

H35.3293

H35.341 - H36

Other retinal disorders


H33.001 -

H33.119

H33.191 -

H33.8

Retinal detachments and defects

H40.001 - H42 Glaucoma

H43.00 -

H43.9

Disorders of vitreous body

H44.601 -

H44.699

Retained (old) intraocular foreign body, magnetic

H44.701 -

H44.799

Retained (old) intraocular foreign body, nonmagnetic

H47.231 -

H47.239

Glaucomatous optic atrophy

H52.10 -

H52.13

Myopia [High axial length myopia (-6.00 Diopters or less [toward -10.00 D])]

H53.121 -

H53.139

Transient or sudden visual loss

H53.15 Visual distortions of shape and size [metamorphopsia]

S00.10x+ -

S00.12x+

S05.10x+ -

S05.12x+

Contusion of eye and adnexa

S05.50x+ -

S05.52x+

Penetrating w ound with foreign body of eyeball

ICD-10 codes not covered for indications listed in the CPB:


D18.09 Hemangioma of other sites [retina]

D57.00 -

D57.1

Sickle-cell disease

D76.3 Other histiocytosis syndromes [juvenile xanthogranuloma]

G10 Huntington's chorea

G11.1 Early-onset cerebellar ataxia [Friedreich's ataxia]

G12.0 - G12.9 Spinal muscular atrophy and related syndromes

G20 Parkinson's disease

G23.0 - G23.9 Other degenerative diseases of basal ganglia


G30.0 - G30.9 Alzheimer's disease

G31.83 Dementia with Lewy bodies

G93.2 Benign intracranial hypertension

H05.111 -

H05.119

Granuloma of orbit [Pseudotumor (inflammatory) of orbit]

H46.00 -

H46.9

Optic neuritis

I72.8 Aneurysm of other specified arteries [ophthalmic]

Q87.1 Congenital malformation syndromes predominantly associated

with short stature [Noonan's syndrome]

Z13.5 Encounter for screening for eye and ear disorders

[retinoblastoma]

Z51.81 Encounter for therapeutic drug level monitoring [for monitoring

of fingolimod (Gilenya) therapy]

The above policy is based on the following references:

1. American Academy of Ophthalmology (AAO). Preferred Practice

Pattern. Comprehensive adult medical eye evaluation. San

Francisco, CA: AAO, 2005.

2. American Academy of Ophthalmology (AAO) Retina Panel.

Preferred Practice Pattern. Diabetic retinopathy. San Francisco, CA:

American Academy of Ophthalmology, 2008.

3. American Optometric Association (AOA). Care of the patient with retinal detachment and related peripheral vitreoretinal disease.

Optometric Clinical Practice Guideline. St Louis, MO: AOA; 1995.

4. National Government Services (NGS). Posteriorsegment imaging

(extended ophthalmoscopy and fundus photography). Medicare

Local Coverage Determination (LCD) No. L25466. Syracuse, NY:

NGC; December 2007.

5. Yilmaz S, Aydemir E, Maden A, et al. The prevalence of ocular

involvement in patients with inflammatory bowel disease. Int J

Colorectal Dis. 2007;22(9):1027-1030.

6. Tung TH, Chen SJ, Shih HC, et al. Assessing the natural course of diabetic retinopathy: A population-based study in Kinmen, Taiwan.

Ophthalmic Epidemiol. 2006;13(5):327-333.

7. Ruggieri M, Pavone P, Polizzi A, et al. Ophthalmological

manifestations in semental neruofibromatosis type 1. Br J

Ophthalmol. 2004;88(11):1429-1433.


8. Fenton S. Kemp EG, Harnett AN. Screening for ophthalmic

involvement in asymptomatic patients with metastatic breast

carcinoma. Eye. 2003;18(1):38-40.

9. Hutchinson A, McIntosh A, Peters J, et al. Effectiveness of screening

and monitoring tests for diabetic retinopathy -- a systematic review.

Diabet Med. 2000;17(7):495-506.

10. Shields JA, Shields CL, De Potter P, et al. Diagnosis and treatment of uveal melanoma. Semin Oncol. 1996;23(6):763-767.

11. Shields JA. Current approaches to the diagnosis and management of choroidal melanomas. Surv Ophthalmol. 1977;21(6):443-463.

12. Section on Ophthalmology American Academy of Pediatrics, American Academy of Ophthalmology, American Association for

Pediatric Ophthalmology and Strabismus. Screening examination of

premature infants for retinopathy of prematurity. Pediatrics.

2006;117(2):572-576.

13. Clark D, Kebede W, Eggenberger E. Optic neuritis. Neurol Clin. 2010;28(3):573-580.


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updated and therefore is subject to change.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0767 Extended

Ophthalmoscopy

There are no amendments for Medicaid.

Revised 10/26/2021

0767 extended ophthalmoscopy medical clinical policy bulletins

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