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Clinical Policy Bulletin:
Fundus Photography
Number: 0539


Policy

  1. Aetna considers fundus photography medically necessary for any of the following indications:

    • Abnormal electro-oculogram (EOG)
    • Abnormal oculomotor studies
    • Abnormal retinal function studies
    • Abnormal visually evoked potential
    • Benign neoplasm of choroid, cranial nerves, eyeball, or retina
    • Carcinoma in situ of eye
    • Chorioretinal inflammation, scars, and other disorders of choroid
    • Color vision deficiencies
    • Congenital anomalies of posterior segment of eye
    • Congenital rubella
    • Diabetes mellitus (diabetic retinopathy)
    • Disorders of aromatic amino-acid metabolism affecting the fundus
    • Disorders of globe
    • Disorders of optic nerve and visual pathways
    • Endophthalmitis
    • Glaucoma and glaucoma suspects
    • Hamartoses involving the eye
    • Histoplasmosis
    • Human immunodeficiency virus (HIV) disease
    • Lupus erythematosus
    • Malignant neoplasm of eye
    • Monitoring of members for toxicity by anti-malarials such as chloroquine (Aralen), hydroxychloroquine (Plaquenil) and drugs acting on other blood protozoa
    • Multiple sclerosis
    • Penetration of eyeball with magnetic or non-magnetic foreign body
    • Peters anomaly
    • Pseudotumor cerebri
    • Retinal detachment and defects
    • Rheumatoid arthritis and other inflammatory polyarthropathies
    • Sickle-cell anemia
    • Syphilitic retrobulbar neuritis
    • Systemic lupus erythematosus
    • Toxoplasmosis
    • Tuberous sclerosis
    • Other retinal disorders where the results of fundus photography will change the treatment of the member.
       
  2. Aetna considers fundus photography experimental and investigational for screening and for all other indications (e.g., toxocariasis) because there is insufficient evidence that this test affects management for these other indications such that clinical outcomes are improved.


Background

Fundus photography involves the use of a retinal camera to photograph the regions of the vitreous, retina, choroid, and optic nerve.  The resultant images may be either photographic or digital and become part of the member's medical record.  Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated.

Fundus photography is indicated to document abnormalities related to disease processes affecting the eye or to follow the progress of the disease, and is considered medically necessary for such conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, or to identify glaucoma, multiple sclerosis, and other central nervous system abnormalities.

Fundus photographs are only considered medically necessary where the results may influence the management of the patient.  In general, fundus photography is performed to evaluate abnormalities in the fundus, follow the progress of a disease, plan the treatment for a disease, and assess the therapeutic effect of recent surgery (e.g., photocoagulation).  Fundus photographs are not medically necessary simply to document the existence of a condition.  However, photographs may be medically necessary to establish a baseline to judge later whether a disease is progressive.

Sequential series of photographs are considered medically necessary only if they document a clinically relevant condition that is subject to change in extent, appearance or size, and where such change would directly affect the management.  Repeat fundus photography may be medically necessary when an examination of the fundus reveals that the disease of condition of the fundus has progressed, such that prior fundus photographs no longer depict the pathology at the present time.  Repeated fundus photographs of the same disease or condition, without any meaningful change, are not considered medically necessary.  In addition to disease progression, repeat fundus photographs may be necessary if there is a new disease affecting the fundus, or for planning for additional surgical treatment.  Routine images to embellish the record, but a succession of which would not influence treatment, are not considered medically necessary.  When performed concurrently, the medical necessity of fundus photography and scanning computerized diagnostic imaging of the posterior segment should be documented in the medical record.

Documentation in the patient's medical record should include a current, pertinent history and physical examination, and progress notes describing and supporting the covered indication for fundus photography, and pertinent prior diagnostic testing and completed report(s), including, when appropriate, previous fundus photographs.  Fundus photographs should be properly labeled as to which eye they represent, the date they were taken, and the date they were reviewed.  The medical records should document the findings of the fundus photography, including a description of changes from prior fundus photographs (if any), and an interpretation of those findings, and the implications of the photographic evidence, including whether any chages in the treatment plan will be instituted as a result of the photographs.  Fundus photographs without an interpretation are considered not medically necessary.  All documentation must be maintained in the member’s medical record.  The record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)), as well as the physician or non-physician practitioner responsible for and providing the care of the patient.

When indicated for glaucoma, the interpretation of the fundus photographs should include a report of the vertical and horizontal cup/disc ratio based upon vessel pattern and/or coloration, the presence or absence of diffuse or focal pallor, the presence or absence of asymmetry, and the presence or absence of progression regarding any of the above parameters.  If the fundus photographs include red-free images, commentary on the status of the retinal nerve fiber layer should accompany the images.

The American Academy of Ophthalmology (Marmor et al, 2011) does not recommend the use of fundus photography for screening of chloroquine and hydroxychloroquine retinopathy.  It is not sensitive enough for screening because recognizable bull's-eye retinopathy signifies relatively advanced chloroquine or hydroxychloroquine toxicity.

Salcone et al (2010) stated that retinopathy of prematurity (ROP) is a vision-threatening vaso-proliferative condition of premature infants worldwide.  As survival rates of younger and smaller infants improve, more babies are at risk for the development of ROP and blindness.  Meanwhile, fewer ophthalmologists are available for bedside indirect ophthalmoscopy screening examinations.  Remote digital imaging is a promising method with which to identify those infants with treatment-requiring or referral-warranted ROP quickly and accurately, and may help circumvent issues regarding the limited availability of ROP screening providers.  The Retcam imaging system is the most common system for fundus photography, with which high-quality photographs can be obtained by trained non-physician personnel and evaluated by a remote expert.  It has been shown to have high reliability and accuracy in detecting referral-warranted ROP, particularly at later post-menstrual ages.  Additionally, the method is generally well-received by parents and is highly cost-effective.

An UpToDate review on "Retinopathy of prematurity" (Paysse, 2012) does not mention the use of digital imaging or fundus photography.  It states that "screening evaluation consists of a comprehensive eye examination performed by an ophthalmologist with expertise in neonatal disorders".

An UpToDate review on “Toxocariasis: visceral and ocular larva migrans” (Weller and Leder, 2013) does NOT mention the use of fundus imaging/photography.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
92250
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus (HIV) disease
084.0 - 084.9 Malaria
094.85 Syphilitic retrobulbar neuritis
115.02 Infection by Histoplasma capsulatum, retinitis
115.12 Infection by Histoplasma duboisil, retinitis
115.92 Histoplasmosis, unspecified, retinitis
130.1 Conjunctivitis due to toxoplasmosis
130.2 Chorioretinitis due to toxoplasmosis
190.0 - 190.9 Malignant neoplasm of eye
198.4 Secondary malignant neoplasm of other parts of nervous system
224.0 Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
224.5 Benign neoplasm of retina
224.6 Benign neoplasm of choroid
225.1 Benign neoplasm of cranial nerves
234.0 Carcinoma in situ of eye
239.81 Neoplasm of unspecified nature of retina and choroid
249.00 - 250.93 Diabetes mellitus
270.2 Other disturbances of aromatic amino-acid metabolism
282.60 - 282.69 Sickle-cell disease
340 Multiple sclerosis
348.2 Benign intracranial hypertension [pseudotumor cerebri]
360.00 - 360.89 Disorders of the globe
361.00 - 361.9 Retinal detachment and defects
362.01 - 362.9 Other retinal disorders
363.00 - 363.9 Chorioretinal inflammations, scars, and other disorders of choroid
365.00 - 365.9 Glaucoma
368.51 - 368.59 Color vision deficiencies
377.00 - 377.9 Disorders of optic nerve and visual pathways
379.21 - 379.29 Disorders of vitreous body
379.32 Subluxation of lens
379.34 Posterior dislocation of lens
695.4 Lupus erythematosus
710.0 Systemic lupus erythematosus
714.0 - 714.9 Rheumatoid arthritis and other inflammatory polyarthropathies
743.44 Specified congenital anomaly of anterior chamber, chamber angle, and related structures [Peter’s anomaly]
743.51 - 743.59 Congenital anomalies of posterior segment
759.5 Tuberous sclerosis
759.6 Other hamartoses, not elsewhere classified
759.81 - 759.89 Other specified anomalies
771.0 Congenital rubella
794.11 Abnormal retinal function studies
794.12 Abnormal electro-oculogram (EOG)
794.13 Abnormal visually evoked potential
794.14 Abnormal oculomotor studies
871.5 Penetration of eyeball with magnetic foreign body
871.6 Penetration of eyeball with (nonmagnetic) foreign body
961.4 Poisoning by antimalarials and drugs acting on other blood protozoa [hydroxychloroquine toxicity]
961.5 Poisoning by other antiprotozoal drugs
ICD-9 codes not covered for indications listed in the CPB: (not all inclusive):
128.0 Toxocariasis


The above policy is based on the following references:
  1. Xact Medicare Services. Fundus Photography. Medicare Medical Policy Bulletin No. M-37. Camp Hill, PA: Xact; April 28, 1997. Available at: http://www.eyecare.org/ecbc/medicare/fundfoto.html. Accessed March 24, 2000.
  2. Louisiana Medicare Services. Fundus photography. Medicare Part B Medical Policy. Baton Rouge, LA: Louisiana Medicare; June 21, 1991. Available at: http://www.lamedicare.com/provider/medpol/fundpho.asp. Accessed March 24, 2000.
  3. Highmark Medicare Services, Inc. Fundus photography. Medicare Local Coverage Determination (LCD) L27498. Medicare Administrative Contractor (MAC) Parts A and B. Camp Hill, PA: Highmark Medicare Services; November 2, 2009.
  4. American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
  5. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
  6. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
  7. American Academy of Ophthalmology (AAO). Primary angle closure. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
  8. American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
  9. American Academy of Ophthalmology. Posterior vitreous detachment, retinal breaks, and lattice degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
  10. Wong D. The fundus camera. In: Duane's Clinical Ophthalmology. Vol. 1. Rev. ed. W Tasman, EA Jaeger, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 1999; Ch. 61:1-14.
  11. Chang DF. Ophthalmologic examination. In: General Ophthalmology. 15th ed. D Vaughan, T Asbury, P Riordan-Eva, eds. Stamford, CT: Appleton & Lange; 1999; Ch. 2:27-56.
  12. Mardin CY, Junemann AG. The diagnostic value of optic nerve imaging in early glaucoma. Curr Opin Ophthalmol. 2001;12(2):100-104.
  13. Shiba T, Yamamoto T, Seki U, et al. Screening and follow-up of diabetic retinopathy using a new mosaic 9-field fundus photography system. Diabetes Res Clin Pract. 2002;55(1):49-59.
  14. Larsen M, Godt J, Larsen N, et al. Automated detection of fundus photographic red lesions in diabetic retinopathy. Invest Ophthalmol Vis Sci. 2003;44(2):761-766.
  15. Williams GA, Scott IU, Haller JA, et al. Single-field fundus photography for diabetic retinopathy screening: A report by the American Academy of Ophthalmology. Ophthalmology. 2004;111(5):1055-1062.
  16. Marmor MF, Carr RE, Easterbrook M, Farjo AA, Mieler WF; American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: A report by the American Academy of Ophthalmology. Ophthalmology 2002;109(7):1377-1382.
  17. Davis MD, Bressler SB, Aiello LP, et al; Diabetic Retinopathy Clinical Research Network Study Group. Comparison of time-domain OCT and fundus photographic assessments of retinal thickening in eyes with diabetic macular edema. Invest Ophthalmol Vis Sci. 2008;49(5):1745-1752.
  18. Polak BC, Hartstra WW, Ringens PJ, Scholten RJ. Revised guideline 'Diabetic retinopathy: Screening, diagnosis and treatment'. Ned Tijdschr Geneeskd. 2008;152(44):2406-2413.
  19. American Diabetes Association. Position statement: Standards of medical care in diabetes - 2010. Diabetes Care. 2010;33(Suppl. 1):S11-S61.
  20. Jain N, Farsiu S, Khanifar AA, et al. Quantitative comparison of drusen segmented on SD-OCT versus drusen delineated on color fundus photographs. Invest Ophthalmol Vis Sci. 2010;51(10):4875-4883.
  21. Marmor MF, Kellner U, Lai TY, et al; American Academy of Ophthalmology. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118(2):415-422.
  22. Salcone EM, Johnston S, VanderVeen D. Review of the use of digital imaging in retinopathy of prematurity screening. Semin Ophthalmol. 2010;25(5-6):214-217.
  23. American Diabetes Association (ADA). Standards of medical care in diabetes. VI. Prevention and management of diabetes complications. Diabetes Care 2011;34(Suppl 1):S27-S38.
  24. Paysse EA. Retinopathy of prematurity. Last reviewed March 2012. UpToDate Inc. Waltham, MA.
  25. Weller PF, Leder K. Toxocariasis: visceral and ocular larva migrans. Last reviewed April 2013. UpToDate Inc. Waltham, MA.
  26. Ku JJ, Landers J, Henderson T, et al. The reliability of single-field fundus photography in screening for diabetic retinopathy: The Central Australian Ocular Health Study. Med J Aust. 2013;198(2):93-96.


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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.
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