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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 with ophthalmic manifestations
    • 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
    • Multiple sclerosis
    • Penetration of eyeball with magnetic or non-magnetic foreign body
    • Monitoring of members for toxicity by anti-malarials such as Plaquenil (hydroxychloroquine) and drugs acting on other blood protozoa
    • Retinal detachment and defects
    • Other retinal disorders
    • Rheumatoid arthritis and other inflammatory polyarthropathies
    • Sickle-cell anemia
    • Syphilitic retrobulbar neuritis
    • Systemic lupus erythematosus
    • Toxoplasmosis
    • Tuberous sclerosis.

  2. Aetna considers fundus photography experimental and investigational for all other indications 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. 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.
 
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
239.8 Neoplasm of unspecified nature of other specified sites
250.00 - 250.93 Diabetes mellitus
270.2 Other disturbances of aromatic amino-acid metabolism
282.60 - 282.69 Sickle-cell disease
340 Multiple sclerosis
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
743.51 - 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


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. American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2006.
  4. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2005.
  5. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2005.
  6. American Academy of Ophthalmology (AAO). Primary angle closure. Preferred Practice Pattern. San Francisco, CA: AAO; 2005.
  7. American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; 2003.
  8. American Academy of Ophthalmology. Posterior vitreous detachment, retinal breaks, and lattice degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2003.
  9. 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.
  10. 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.
  11. Mardin CY, Junemann AG. The diagnostic value of optic nerve imaging in early glaucoma. Curr Opin Ophthalmol. 2001;12(2):100-104.
  12. 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.
  13. 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.
  14. 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.
  15. 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.


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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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