External Ocular Photography

Number: 0734

Policy

Aetna considers external ocular photography medically necessary for the following indications to track and serially compare the changes of the condition, where the results may have an impact on management and clinical outcomes:

• Acid chemical burn of cornea and conjunctival sac
• Acute inflammation of orbit, unspecified
• Adherent leucoma
• Adhesions of iris, unspecified
• Alkaline chemical burn of cornea and conjunctival sac
• Anterior dislocation of lens
• Anterior pigmentation
• Anterior synechiae
• Argentous deposits
• Band-shaped keratopathy
• Benign neoplasm of conjunctiva
• Benign neoplasm of cornea
• Benign neoplasm of eye, part unspecified
• Benign neoplasm of eyeball, except retina and choroid
• Benign neoplasm of eyelid, including canthus
• Benign neoplasm of lacrimal duct
• Benign neoplasm of lacrimal gland
• Benign neoplasm of orbit
• Benign neoplasm of other specified parts of eye
• Benign neoplasm of skin of other and unspecified parts of face
• Blisters, with epidermal loss due to burn (second degree) of eye (with other parts of face, head, and neck)
• Bullous keratopathy
• Burn of unspecified degree of eye (with other parts of face, head, and neck)
• Burn with resulting rupture and destruction of eyeball
• Carcinoma in situ of eye
• Carcinoma of eyelid, including canthus
• Central corneal ulcer
• Central opacity of cornea
• Chemical burn of eyelids and periocular area
• Congenital ptosis
• Conjunctival melanosis
• Constant exophthalmos
• Corneal abscess
• Corneal deformity, unspecified
• Corneal degeneration, unspecified
• Corneal deposit, unspecified
• Corneal dystrophy, unspecified
• Corneal ectasia
• Corneal edema due to wearing of contact
• Corneal edema, unspecified
• Corneal membrane change, unspecified
• Corneal neovascularization, unspecified
• Corneal opacity, unspecified
• Corneal staphyloma
• Corneal ulcer, unspecified
• Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), without mention of loss of body part
• Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), with loss of a body part
• Deep vascularization of cornea
• Degeneration of pupillary margin
• Degenerative changes of chamber angle
• Degenerative changes of ciliary body
• Dermatochalasis of upper eyelids
• Descematocele
• Diffuse interstitial keratitis
• Double pterygium, to follow in lieu of surgery
• Endothelial corneal dystrophy
• Ectropion
• Entropion
• Erythema due to burn (first degree) of eye (with other parts face, head, and neck)
• Essential or progressive iris atrophy
• Exophthalmic ophthalmoplegia
• Exophthalmos, unspecified
• Exudative cysts of iris or anterior chamber
• Floppy eyelid syndrome
• Folds and rupture of Bowman's membrane
• Folds in Descemet's membrane
• Full-thickness skin loss due to burn (third degree NOS) of eye (with other parts of face, head, and neck)
• Goniosynechiae
• Granular corneal dystrophy
• Herpes simplex disciform keratitis
• Herpes zoster keratoconjunctivitis
• Hyphema
• Hypopyon
• Hypopyon ulcer
• Idiopathic corneal edema
• Idiopathic cysts
• Implantation cysts
• Interstitial keratitis, unspecified
• Iridoschisis
• Juvenile epithelial corneal dystrophy
• Kayser-Fleischer ring
• Keratoconus, acute hydrops
• Keratoconus, stable condition
• Keratoconus, unspecified
• Keratomalacia NOS
• Late effect of other and unspecified external causes
• Lattice corneal dystrophy
• Limbal and corneal involvement in vernal conjunctivitis
• Localized adhesions and strands of conjunctiva
• Localized vascularization of cornea
• Macular corneal dystrophy
• Malignant neoplasm of conjunctiva, unless excision is planned
• Malignant neoplasm of the cornea, unless excision is planned
• Marginal corneal ulcer
• Minor opacity of cornea
• Miotic cysts of pupillary margin
• Mooren's ulcer
• Mycotic corneal ulcer
• Neurotrophic keratoconjunctivitis
• Nodular degeneration of cornea
• Orbital cellulitis
• Other and unspecified superficial injuries of eye
• Other anterior corneal dystrophies
• Other burn of cornea and conjunctival sac
• Other burns of eyelids and periocular area
• Other calcareous degeneration of cornea
• Other corneal degenerations
• Other deposits associated with metabolic disorders
• Other disorders of iris and ciliary body
• Other forms of keratitis (e.g., superficial punctate keratopathy)
• Other posterior corneal dystrophies
• Other stromal corneal dystrophies
• Pannus (corneal)
• Perforated corneal ulcer
• Peripheral degenerations of cornea
• Peripheral opacity of cornea
• Peripheral pterygium, progressive, to follow in lieu of surgery
• Phacolytic glaucoma
• Phlyctenular keratoconjunctivitis
• Pigmentary iris degeneration
• Posterior dislocation of lens
• Posterior pigmentations
• Posterior synechiae
• Pseudopterygium
• Pterygium, unspecified, to follow in lieu of surgery
• Ptosis of eyelid
• Pupillary abnormalities
• Pupillary membranes
• Recession of chamber angle
• Recurrent erosion of cornea
• Recurrent pterygium, to follow in lieu of surgery
• Ring corneal ulcer
• Rubeosis iridis
• Rupture in Descemet's membrane
• Scleral melanosis
• Sclerosing keratitis
• Secondary corneal edema
• Stromal pigmentations
• Subluxation of lens
• Superficial injury of conjunctiva
• Superficial injury of cornea
• Superficial injury of eyelids and periocular area
• Symblepharon
• Thyrotoxic exophthalmos
• Unspecified burn of eye and adnexa
• Unspecified corneal disorder
• Unspecified disorder of iris and ciliary body
• Unspecified keratitis
• Vascular anomalies of eyelid.

External ocular photography has no proven value for other indications (e.g., anterior scleritis, epiblepharon with trichiasis, evaluating conjunctival hemorrhage, keratoconjunctivitis sicca, and monitoring pinguecula).

Aetna considers external ocular photography not medically necessary for the sole purpose of documenting the existence of an ocular condition in order to enhance the medical record.

Background

External ocular photography can be used to document the progress or deterioration of certain conditions of the external structures of the eye including the eyelids, lashes, sclerae, conjunctiva and cornea.  It may also be used to document progress and deterioration of structures of the anterior chamber including the iris, and filtration angle.  These photographs are commonly made using slit lamp photography, goniophotography, stereophotography or close-up photography.  Regardless of the technique used for the picture taking, the pictures may be stored as prints, slides, videotape or digital medium.

External ocular photography is clinically useful for tracking slowly progressive conditions over prolonged periods of time, where it may be impractical to document progression with hand drawings due to the need to document fine detail, especialy where there is a lack of anatomic landmarks.

Anterior Scleritis

An UpToDate review on “Slit lamp examination” (Knoop, 2020) does not mention scleritis as an indication.

Epiblepharon with Trichiasis

An UpToDate review on “Approach to the child with persistent tearing” (Paysse et al, 2016) states that “Eyelid abnormalities -- Anatomic abnormalities of the eyelids may cause tearing, redness, and foreign body sensation. Trichiasis (ingrown eyelashes) can irritate the cornea, causing reflex tearing and redness, and may be caused by entropion or epiblepharon.  Entropion is the in-turning of the eyelid; epiblepharon is a fold of skin along the lower lid margin, just below the eyelashes.  Both of these conditions can be associated with trichiasis.  Entropion, if significant, is treated with surgical repair.  Children usually outgrow epiblepharon by 2 to 3 years of age without needing to undergo surgery”.  This review does not mention external ocular photography as a management tool.

Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES), a subtype of lax eyelid conditions, often involves over-weight individuals.  It is a distressing condition that can cause significant morbidity and vision loss.  The cause of FES is believed to be a mechanical disorder due to the eversion of the lids while sleeping.  It is usually characterized by chronic eye irritation and an increased laxity of the upper eyelid that can be easily everted by applying minimal upward traction.  Floppy eyelid syndrome has also been reported to be associated with obstructive sleep apnea-hypopnea syndrome.  Blepharoptosis is one of the most common features, which links to FES, for which a thorough differential diagnosis has become important in directing proper medical treatment.  Furthermore, FES can cause superficial corneal and conjunctival injuries; and external ocular photography can be used to document the appearance of the eyelid margin and inferior cornea, and to develop a treatment plan (Donnenfeld et al, 1991, Ezra et al, 2010, and Lee et al, 2018).

Keratoconjunctivitis Sicca

Rutar et al (2015) determined the ophthalmic manifestations of HIV in a cohort of long-term survivors of perinatally acquired HIV.  A total of 22 patients with perinatally acquired HIV who were aged greater than or equal to 12 years were prospectively studied at a university clinic.  They underwent complete ophthalmic examinations and fundus photography.  Their medical histories, medications and CD4 counts were abstracted from the medical records.  To evaluate for kerato-conjunctivitis sicca (KCS), both HIV patients and 44 healthy controls (matched by age, gender and contact lens wear) underwent Schirmer testing and ocular surface staining; 9 male and 13 female HIV patients with mean age of 16.6 years (SD, 3.4) were examined.  Of the 22 HIV patients, 21 had been treated with highly active anti-retroviral therapy (HAART).  Only 1 patient had a CD4 count nadir of less than 200 cells/µL.  The mean visual acuity (VA) of the eyes of the HIV subjects was 20/22 (SD, 1.6 lines).  No patient had cytomegalovirus retinitis; 4 of the 22 (18 %) HIV patients had strabismus.  HIV subjects and controls had similar rates of abnormal Schirmer (9 % and 14 %, p = 0.62) and ocular staining scores (p = 0.29).  The authors concluded that in the post-HAART era, long-term survivors of perinatally acquired HIV exhibited little vision-threatening disease, but had a high prevalence of strabismus.

Safonova et al (2016) noted that laser confocal tomography of the cornea enables studying ultrathin sections of corneal layers, which provides additional reliable information on tissue changes in KCS.  These researchers evaluated the significance of laser confocal tomography of the cornea in the diagnosis and monitoring of KCS.  They investigated 38 eyes of 30 patients with severe KCS.  The patients were divided into 2 groups: Group 1 (15 patients, 19 eyes) was prescribed cyclosporine А 0.05 % instillations 2 times daily, artificial tears, and soft contact lenses, and Group 2 (15 patients, 19 eyes) received only instillations of cyclosporine А 0.05% 2 times daily and artificial tears.  Besides standard ophthalmic examination, additional tests were performed, namely Schirmer's test, tear break-up time test, fluorescein eye stain test, tear osmolarity test (TearLab System, USA), and Heidelberg retinal tomography of the cornea (HRT, Heidelberg Engineering GmbH, Germany).  HRT findings revealed a 3 times shorter epithelization period and faster recovery of corneal transparency in Group 1 as compared to Group 2 (1.5 and 4.5 months, respectively).  There was also an evident reduction in the number of immune cells in the cornea, most pronounced in group 1 at 3 months, which was indicative of inflammation termination.  The authors concluded that the use of HRT of the cornea in KCS patients allowed real-time cellular level observation of corneal changes, which together with clinical findings and diagnostic tests not only confirmed the diagnosis but also determined treatment effectiveness.  It has been also found that soft contact lenses accelerated epithelization of the cornea and relieved inflammation of the ocular surface in KCS patients under cyclosporine A 0.05 % instillation therapy.

An UpToDate review on “Diagnosis and classification of Sjögren's syndrome” (Baer , 2017a) states that “KCS is characterized primarily by a deficiency in tear production, while hypovitaminosis A is characterized by disordered conjunctival and corneal epithelial turnover, leading to keratinization and a loss of conjunctival goblet cells, resulting in tear mucin deficiency”; it does not mention ocular photography as a management tool.

An UpToDate review on “Clinical manifestations of Sjögren's syndrome: Exocrine gland disease” (Baer, 2017b) does not mention ocular photography as a management tool.

Furthermore, an American Academy of Ophthalmology’s guideline on “Dry eye syndrome” (AAO, 2013) had no recommendation for external ocular photography, either for diagnosis or follow-up.  

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
92285	External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography)
ICD-10 codes covered if selection criteria are met:
B00.52	Herpesviral keratitis
B02.33	Zoster keratitis
C44.101 - C44.1992	Other and unspecified malignant neoplasm of eyelid, including canthus
C69.00 - C69.02	Malignant neoplasm of conjunctiva
C69.10 - C69.12	Malignant neoplasm of cornea
D04.10 - D04.122	Carcinoma in situ of skin of eyelid, including canthus
D09.20 - D09.22	Carcinoma in situ of eye
D23.10 - D23.122	Other benign neoplasm of skin of eyelid, including canthus
D23.30 - D23.39	Other benign neoplasm of skin of other and unspecified parts of face
D31.00 - D31.02	Benign neoplasm of conjunctiva
D31.10 - D31.12	Benign neoplasm of cornea
D31.40 - D31.42	Benign neoplasm of ciliary body
D31.50 - D31.52	Benign neoplasm of lacrimal gland and duct
D31.60 - D31.62	Benign neoplasm of unspecified site of orbit
D31.90 - D31.92	Benign neoplasm of unspecified part of eye
H02.001 - H02.049	Unspecified entropion of eyelid
H02.102 - H02.159	Ectropion of eyelid
H02.401 - H02.439	Ptosis of eye
H02.831	Dermatochalasis of right upper eyelid
H02.834	Dermatochalasis of left upper eyelid
H02.871 - H02.879	Vascular anomalies of eyelid
H02.89	Other specified disorders of eyelid [floppy eyelid syndrome]
H05.00	Unspecified acute inflammation of orbit
H05.011 - H05.019	Cellulitis of orbit
H05.20	Unspecified exophthalmos
H05.241 - H05.249	Constant exophthalmos
H05.89	Other disorders of orbit [thyrotoxic exophthalmos, exophthalmic ophthalmoplegia]
H11.001 - H11.019	Unspecified and amyloid pterygium of eye
H11.031 - H11.039	Double pterygium of eye
H11.051 - H11.059	Peripheral pterygium of eye, progressive
H11.061 - H11.069	Recurrent pterygium of eye
H11.131 - H11.139	Conjunctival pigmentations [melanosis]
H11.211 - H11.219	Conjunctival adhesions and strands (localized)
H11.231 - H11.239	Symblepharon
H11.811 - H11.819	Pseudopterygium of conjunctiva
H15.89	Other disorders of sclera [melanosis]
H16.001 - H16.079	Corneal ulcer
H16.101 - H16.149	Unspecified superficial keratitis
H16.201 - H16.229	Unspecified keratoconjunctivitis
H16.231 - H16.239	Neurotrophic keratoconjunctivitis
H16.241 - H16.249	Ophthalmia nodosa
H16.251 - H16.259	Phlyctenular keratoconjunctivitis
H16.261 - H16.269	Vernal keratoconjunctivitis, with limbal and corneal involvement
H16.291 - H16.299	Other keratoconjunctivitis
H16.301 - H16.309	Unspecified interstitial keratitis
H16.311 - H16.319	Corneal abscess
H16.321 - H16.329	Diffuse interstitial keratitis
H16.331 - H16.339	Sclerosing keratitis
H16.391 - H16.399	Other interstitial and deep keratitis
H16.401 - H16.409	Unspecified corneal neovascularization
H16.411 - H16.419	Ghost vessels (corneal)
H16.421 - H16.429	Pannus (corneal)
H16.431 - H16.439	Localized vascularization of cornea
H16.441 - H16.449	Deep vascularization of cornea
H16.8	Other keratitis
H16.9	Unspecified keratitis
H17.00 - H17.9	Corneal scars and opacities
H18.001 - H18.069	Corneal pigmentations and deposits
H18.10 - H18.13	Bullous keratopathy
H18.20 - H18.239	Other and unspecified corneal edema
H18.30 - H18.339	Changes of corneal membranes
H18.40	Unspecified corneal degeneration
H18.421 - H18.429	Band keratopathy
H18.43	Other calcerous degeneration of cornea
H18.441 - H18.449	Keratomalacia
H18.451 - H18.459	Nodular corneal degeneration
H18.461 - H18.469	Peripheral corneal degeneration
H18.49	Other corneal degeneration
H18.50 - H18.59	Hereditary corneal dystrophies
H18.601 - H18.629	Keratoconus
H18.70 - H18.799	Other and unspecified corneal deformities
H18.831 - H18.839	Recurrent erosion of cornea
H18.9	Unspecified disorder of cornea
H20.051 - H20.059	Hypopyon
H21.00 - H21.279 H21.301 - H21.329 H21.40 - H21.529 H21.541 - H21.569 H21.81, H21.89 - H21.9	Other disorders of iris and ciliary body
H27.10 - H27.139	Dislocation of lens
H40.50x0 - H40.53x4	Glaucoma secondary to other eye disorders [Phacolytic glaucoma]
Q10.0	Congenital ptosis
S00.201+ - S00.279+	Other and unspecified superficial injuries of eyelid and periocular area
S05.00x+ - S05.02x+	Injury of conjunctiva and corneal abrasion without foreign body
S05.90x+ - S05.92x+	Unspecified injury of eye and orbit
T26.00x+ - T26.92x+	Burns and corrosion confined to eye and adnexa
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
H02.051 - H02.059	Trichiasis without entropian
H11.151 - H11.159	Pinguecula
H11.30 - H11.33	Conjunctival hemorrhage
H15.011 - H15.019	Anterior scleritis
H16.221 - H16.229	Keratoconjunctivitis sicca, not specified as Sjögren's
Q10.3	Other congenital malformations of eyelid [epiblepharon]

The above policy is based on the following references: