Extended Ophthalmoscopy

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Aetna Better Health® 2000 Market Street, Suite 850 Philadelphia, PA 19103

AETNA BETTER HEALTH®

Clinical Policy Bulletin: Extended Ophthalmoscopy Revised April 2014

Number: 0767

Policy 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 rupture, 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 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

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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. 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. 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 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.

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.

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Extended Ophthalmoscopy

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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.

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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CPT Codes / HCPCS Codes / ICD-9 Codes CPT codes covered if selection criteria are met: 92225 92226 ICD-9 codes covered if selection criteria are met: 190.5

Malignant neoplasm of retina

190.6

Malignant neoplasm of choroid

224.6

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

250.50 250.53

Diabetes with ophthalmic manifestations, type I [juvenile type], type II or unspecified type, not stated as controlled

364.22

Glaucomatocyclitic crises

366.41

Diabetic cataract

377.14

Glaucomatous atrophy (cupping) of optic disc

360.00 360.44

Disorders of the globe

360.50 360.59

Retained (old) intraocular foreign body, magnetic

360.60 360.69

Retained (old) intraocular foreign body, nonmagnetic

361.00 -

Retinal detachments and defects

361.9 362.01 -

Other retinal disorders

362.89

363.00 - Chorioretinal inflammations, scars, and other disorders of choroid 363.9

364.24

Vogt-Koyanagi syndrome

365.00 365.04

Borderline glaucoma [glaucoma suspect]

365.10 365.9

Glaucoma [uncontrolled glaucoma]

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368.11

Sudden visual loss

368.12

Transient visual loss

368.14

Visual distortions of shape and size [metamorphopsia]

376.6

Retained (old) foreign body following penetrating wound of orbit

379.07

Posterior scleritis

379.21 379.29

Disorders of vitreous body

871.5

Penetration of eyeball with magnetic foreign body

871.6

Penetration of eyeball with (nonmagnetic) foreign body

921.0 - 921.3

Contusion of eye and adnexa

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ICD-9 codes not covered for indications listed in the CPB: 228.03

Hemangioma of retina

282.60 282.69

Sickle-cell disease

331.0

Alzheimer’s disease

331.82

Dementia with Lewy bodies

332.0

Parkinson's disease

333.0

Other degenerative diseases of the basal ganglia

333.4

Huntington's chorea

334.0

Friedreich's ataxia

335.10 335.19

Spinal muscular atrophy

335.20

Amyotrophic lateral sclerosis

348.2

Benign intracranial hypertension

377.30 -

Optic neuritis

377.39

442.89

Aneurysm of other specified site [ophthalmic]

759.89

Other specified anomalies [Noonan's syndrome]

V58.83

Encounter for therapeutic drug monitoring [for monitoring of fingolimod (Gilenya) therapy]

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V80.2

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Screening for other eye conditions [retinoblastoma]

Other ICD-9 codes related to the CPB: 115.02

Retinitis due to histoplasma capsulatum

115.92

Ocular histoplasmosis

130.2

Chorioretinitis due to toxoplasmosis

190.0

Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid

198.4

Secondary malignant neoplasm of other parts of nervous system [retina, choroid]

224.5

Benign neoplasm, retina

225.1

Benign neoplasm of cranial nerves

234.0

Carcinoma in situ of eye [retina, choroid]

237.70 237.79

Neurofibromatosis

250.00 250.53

Diabetes mellitus

360.81 360.9

Other and unspecified disorders of globe

364.00 364.23, 364.3 - 364.9

Disorders of the iris and ciliary body

368.10

Subjective visual disturbance, unspecified

368.13

Visual discomfort [photophobia, as evidence of suspected endophthalmitis]

368.15

Other visual distortions and entoptic phenomena

368.16

Psychophysical visual disturbances

368.40 -

Visual field defects

368.47

368.60 368.69

Night blindness

368.8 - 368.9

Other and unspecified visual disturbance

369.00 369.08

Profound impairment, both eyes [as evidence of suspected endophthalmitis]

369.60 369.69

Profound impairment, one eye [as evidence of suspected endophthalmitis]

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374.53

Hypopigmentation of eyelid

376.40 376.47

Deformity of orbit

376.50 376.52

Enophthalmos

377.00 377.04

Papilledema

377.10 377.13, 377.15 377.16

Optic atrophy [covered if associated with a progressive and potentially reversible cause (i.e., glaucoma)]

377.21 377.24

Other disorders of optic disc

377.41 377.49

Other disorders of optic nerve

377.51 377.54

Disorders of optic chiasm

379.32

Subluxation of lens

379.34

Posterior dislocation of lens

379.91

Pain in or around eye [severe, as evidence of suspected endophthalmitis]

379.93

Redness or discharge of eye [as evidence of suspected endophthalmitis]

388.40

Abnormal auditory perception, unspecified [dysacousia]

704.0

Variations in hair color [poliosis]

709.01

Vitiligo

714.0

Rheumatoid arthritis

714.30 714.33

Juvenile chronic polyarthritis

743.51 743.59

Congenital anomalies of posterior segment

759.5

Tuberous sclerosis

759.6

Other hamartoses, not elsewhere classified

759.82

Marfan syndrome

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854.00 854.09

Intracranial injury of other and unspecified nature [meningeal irritation]

870.0

Laceration of eyelid and periocular area

870.1

Laceration of eyelid, full-thickness, not involving lacrimal passages

870.2

Laceration of eyelid involving lacrimal passages

870.3

Penetrating wound of orbit, without mention of foreign body

870.4

Penetrating wound of orbit with foreign body

870.8

Other specified open wounds of ocular adnexa

871.0

Ocular laceration without prolapse of intraocular tissue

871.1

Ocular laceration with prolapse or exposure of intraocular tissue

871.7

Unspecified ocular penetration

871.9

Unspecified open wound of eyeball

918.0 - 918.9

Superficial injury of eye and adnexa

958.1

Fat embolism as an early complication of trauma

995.50 995.59

Child maltreatment syndrome

V58.69

Long-term (current) use of other medications [not covered for individuals on methotrexate or tamoxifen therapy]

V67.51

Follow-up examination; completed treatment with high-risk medication, not elsewhere classified

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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. Available at: http://one.aao.org/asset.axd?id=f49066eb-0297-4b65820a-ee59e398bbd8. Accessed December 21, 2009. 2. American Academy of Ophthalmology (AAO) Retina Panel. Preferred Practice Pattern. Diabetic retinopathy. San Francisco, CA: American Academy of Ophthalmology, 2008. Available at: http://one.aao.org/asset.axd?id=7600c8ae-b7d7-49e7-b126-4d7d00fac893. Accessed December 21, 2009. 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. Available at: http://www.aoa.org/documents/CPG-13.pdf. Accessed June 10, 2008. 4. National Government Services (NGS). Posterior segment 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):14291433. 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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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. CPT only copyright 2008 American Medical Association. All Rights Reserved.

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