Extended Ophthalmoscopy

Number: 0767

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses extended ophthalmoscopy.

1. Medical Necessity

   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:

   1. Blunt injury to the eye or periorbital structures; or
   2. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment; or
   3. Choroidal nevus being evaluated for malignant transformation; or
   4. Degenerative disorders of the globe; or
   5. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy retinal vascular occlusion, or separation of the retinal layers); or
   6. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment); or
   7. High axial length myopia (-6.00 Diopters or less [toward -10.00 D]); or
   8. High-risk medication for retinopathy or optic neuropathy; or
   9. HIV retinopathy; or
   10. Macular degeneration; or
   11. Malignant neoplasm of the retina or choroid; or
   12. Metamorphopsia; or
   13. Optic atrophy associated with a progressive and potentially reversible cause (e.g., glaucoma); or
   14. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye; or
   15. Posterior scleritis; or
   16. Retained (old) intra-ocular foreign body, either magnetic or non-magnetic; or
   17. Retinal defects without retinal detachment; or
   18. Retinal detachment, with or without retinal defect; or
   19. Retinal edema; or
   20. Retinal hemorrhage, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration; or
   21. Retinopathy of prematurity; or
   22. Retinoschisis and retinal cysts; or
   23. Sudden visual loss or transient visual loss; or
   24. Suspected endophthalmitis as evidenced by severe pain, redness, photophobia, and profound loss of vision; or
   25. Symptoms suggestive of retinal defect; or
   26. Systemic disorders associated with retinal pathology; or
   27. Uncontrolled glaucoma or glaucoma suspect; or
   28. 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.
       
       Aetna considers 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.

2. Experimental and Investigational

   Aetna considers the extended ophthalmoscopy with a detailed retinal drawing experimental and investigational for the following indications because the effectiveness of this approach for these indications has not been established (not an all-inclusive list):

   1. Congenital hypertrophy of the retinal pigment epithelium
   2. Juvenile xanthogranuloma
   3. Monitoring of fingolimod (Gilenya) therapy
   4. Monitoring methotrexate or tamoxifen therapy
   5. Monitoring of individuals on checkpoint inhibitors (e.g., ipilimumab and nivolumab)
   6. 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)
   7. Noonan's syndrome
   8. Ophthalmic artery aneurysm
   9. Optic neuritis
   10. Peri-papillary atrophy
   11. Pseudotumor cerebri (orbital pseudotumor)
   12. Retinal angioma
   13. Retinochoroidal coloboma of iris
   14. Screening for retinoblastoma
   15. Sickle cell disease
   16. Staphyloma posticum (posterior staphyloma)
   17. Surveillance of ocular melanoma members with a history of cutaneous melanoma.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
92201	Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral
92202	with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral
ICD-10 codes covered if selection criteria are met:
B20	Human immunodeficiency virus [HIV] disease
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 - 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	Diabetes mellitus due to underlying condition with ophthalmic complications
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 wound 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 [not covered for Peri-papillary atrophy]
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 wound 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]
Q13.0	Coloboma of iris
Q87.1	Congenital malformation syndromes predominantly associated with short stature [Noonan's syndrome]
Z08	Encounter for follow-up examination after completed treatment for malignant neoplasm [surveillance of ocular melanoma with a history of cutaneous melanoma]
Z12.89	Encounter for screening for malignant neoplasm of other sites [surveillance of ocular melanoma with a history of cutaneous melanoma]
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]
Z85.820	Personal history of malignant melanoma of skin [surveillance of ocular melanoma with a history of cutaneous melanoma]

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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 ophthalmsocopy.  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 can not 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.

Monitoring of Individuals on Checkpoint Inhibitors (e.g., Ipilimumab and Nivolumab)

The Prescribing Information of ipilimumab and nivolumab do not mention the need of a baseline extended ophthalmoscopy or their uses in monitoring patients receiving the medication (BMS, 2023).

Surveillance of Ocular Melanoma Members with a History of Cutaneous Melanoma

National Comprehensive Cancer Network’s clinical practice guideline on “Melanoma: Cutaneous” (Version 3.2022) does not mention extended ophthalmoscopy as a management tool.

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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.

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References