External Ocular Photography
Number: 0734
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses external ocular photography.
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Medical Necessity
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
- Blepharitis
- 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
- Chalazion (eyelid cyst)
- Chemical burn of eyelids and periocular area
- Cicatricial pemphigoid
- 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
- Eyelid and/or periorbital swelling
- 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)
- Giant papillary conjunctivitis
- 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
- Lagophthalmos (cicatricial, mechanical, and paralytic)
- 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 involving the orbit
- Malignant neoplasm of the 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
- Ocular surface squamous neoplasia
- 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
- Strabismus
- 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, collapsed orbital wall, enophthalmos following orbital floor fracture, epiblepharon with trichiasis, sinonasal tumor, evaluating conjunctival hemorrhage, keratoconjunctivitis sicca, recurrent dacryoadenitis and recurrent episcleritis, monitoring pinguecula, ocular rosacea, for use following rectus muscle surgery for exotropia, and White-Sutton syndrome).
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.
The frequency with which external ocular photography should be performed is based on the member's underlying condition and the usual progression of that condition. This service should not be repeated and is considered not medically necessary if there has been no change in the member’s conditions.
In some cases, it is expected that this service would be medically necessary once yearly. However, in certain conditions, this test may be medically necessary and appropriate more frequently.
Documentation Requirements:
External ocular photography is accomplished by using a slit-lamp-integrated camera, photography through a goniophotography lens or with a close-up stereo camera. External ocular photographs may be print, slide, video or digital media, and copies must be available for review if requested. External ocular photography is covered only when a special camera is used to obtain magnified photographs of lesions (e.g., the cornea, iris or lids) for the purpose of following the member’s condition. Medical quality images may be digital, Polaroid Macro 3 SLF or equivalent.
Photographs must be permanently labeled with the member’s name and date, and a notation of which eye is pictured. In addition to the photograph(s), an interpretation and report specific to the photograph(s) must be maintained in the member's medical record and be available upon request. External ocular photography without accompanying member identification and date permanently affixed to the photograph will be considered not medically necessary and will be denied.
If additional photographs are taken to track changes in the member’s condition, written documentation describing changes is required and must be maintained in the member’s medical record. An interpretation of the photograph(s) with comparison to prior photographs, if available, must be maintained in the member’s medical record and available for review, if requested.
Note: Photography may be reported only once per session, even though multiple views may be taken.
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, gonio-photography, stereo-photography 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, especially 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.
Ocular Rosacea
UpToDate reviews on “Management of rosacea” (Maier, 2021) and “Rosacea: Pathogenesis, clinical features, and diagnosis” (Dahl, 2021) do not mention external ocular photography as a management tool.
Ocular Surface Squamous Neoplasia
In a retrospective, interventional, case-series study, Chaugule et al (2018) reported on the safety and effectiveness of topical chemotherapy alone for giant ocular surface squamous neoplasia (OSSN). A total of 10 eyes with giant OSSN underwent exfoliative biopsy to confirm the diagnosis followed by application of interferon alpha 2b (IFN α2b) and/or 1 % 5-fluorouracil (5-FU). Outcome measures were tumor response, VA, recurrence, systemic metastasis, and treatment complications. A total of 10 patients (3 women, 7 men) had a mean age of 73 years (median of 69; range of 40 to 89). Mean tumor diameter was 13.1 (median of 12.3; range of 8.2 to 19.4) mm; 5 (50 %) eyes were treated with IFN-α2b alone; 1 (10 %) with 5-FU alone and 4 (40 %) required both IFN-α2b and 5-FU. The mean duration of treatment was 3, 0.5, and 6.4 months for IFN-α2b alone, 5-FU alone, and both IFN-α2b and 5-FU, respectively. Tumor size was determined by direct method with slit-lamp biomicroscopy or by indirect method, using anterior segment photography. Complete tumor response was observed in all 10 cases at mean follow-up of 12.8 months (median of 11.5; range of 3 to 25). Complications included transient irritation and burning (n = 4), dry eyes (n = 2), and transient flu-like symptoms (n = 2). There was no evidence of chemotherapy-related symblepharon, stem cell deficiency, scleral thinning, or corneal opacity. There were no tumor recurrences, and no patient required surgical excision or cryotherapy. The authors concluded that topical chemotherapy was a safe and effective treatment, inducing complete regression in all cases of giant OSSN in this series. There were no sight-limiting complications.
Sun and Hua (2019) examined the angiographic characteristics of OSSN and assessed the effectiveness of sub-conjunctival/peri-lesional 5-FU injections in OSSN cases. A total of 6 eyes of 6 patients with primary OSSN, received peri-lesional, sub-conjunctival, 25 mg/ml 5-FU injections at certain intervals. Anterior segment (AS) digital photography images, AS optical coherence tomography (AS-OCT), and conjunctival indocyanine green angiography (ICGA) were obtained simultaneously with fluorescein angiography (FA). The mean best-corrected vision acuity (BCVA) significantly improved after treatment. At baseline, the median of the largest thickness of OSSN was 905.0 μm (inter-quartile range [IQR]: 492.0 to 1592.5) based on AS-OCT data. There was an abrupt transition between normal and abnormal epithelium, a thickened hyper-reflective epithelium, and a sharp plane of cleavage between the lesion and underlying tissue, all indicative of OSSN. The angiographic characteristics of OSSN included focal or seafan-shaped intra-tumoral and conjunctival feeding vessels visible via ICGA, and abnormal vascular leakage visible with FA. The median time to tumor regression after treatment was 35.0 days (IQR: 32.0 to 45.5) in 5 eyes without recurrence, and OSSN in 1 eye regressed partially 40 days after treatment. The authors concluded that this was the 1st report of the angiographic characteristics of OSSN and its response to sub-conjunctival/peri-lesional 5-FU injections by simultaneous conjunctival angiography and AS-OCT. The improved sub-conjunctival/peri-lesional 5-FUinjection was an effective therapy for OSSN in both BCVA gain and anatomic outcomes.
StatPearls’ review on “Ocular surface squamous neoplasia” (Gurnani and Kaur, 2023) stated that “Although it is very well known that OSSN is sometimes difficult to diagnose clinically on routine slit-lamp examination, excision biopsy and histopathological examination are warranted to subclassify the tumor or when the diagnosis is in doubt. The introduction of ASOCT in OSSN diagnosis came as a boon for all ophthalmologists providing higher axial resolution and rapid scanning speed, thus improving the tumor diagnosis. It is a very vital tool for the cross-sectional evaluation of OSSN. Recently, newly built non-invasive, non-contact, spectral-domain, ultra-high-resolution ASOCT has been built up to map OSSN involving all the corneal layers easily. It reveals any epithelial thickening, epithelial activity, stromal invasion, delineate tumor margin, and normal from abnormal tissue. It also helps to locate the depth of the tumor”.
Recurrent Dacryoadenitis
StatPearls’ webpage on “Dacryoadenitis” (Patel and Patel, 2022) does not mention external ocular photography as an evaluation tool.
Recurrent Episcleritis
StatPearls’ webpage on “Episcleritis” (Schonberg and Stokkermans, 2022) does not mention external ocular photography as an evaluation tool.
White-Sutton Syndrome
White-Sutton syndrome (WHSUS) is a rare neurodevelopmental disorder that affects different systems of the human body. It is mainly characterized by developmental delay, intellectual disability, cranio-facial abnormalities and commonly features of autism spectrum disorder (ASD). However, there is a lack of evidence to support the use of external ocular photography in member with de novo White-Sutton syndrome.
Chalazion
Chalazion, also known as eyelid cyst, is a small (2 to 8 mm), painless nodule caused by obstruction of the meibomian gland. A chalazion is more common on the upper eyelid; and it is possible to have several at once, in more than 1 eyelid. Chalazion is most commonly found in adults between the ages of 30 and 50 years; and it usually develops over days to weeks and is presented with localized eyelid swelling. External examination of the eye includes lid structure, skin texture, as well as eyelash appearance; examination of the inner eyelid demonstrates a non-tender, rubbery nodule. It is usually treated by warm, wet compresses, as well as antibiotic ointments, drops and medicines. External ocular photography can be used to track and serially compare the changes of the condition to examine if conservative treatment is effective or there is a need for need for invasive interventions – steroid injection or surgical removal of the chalazion.
References
The above policy is based on the following references:
- American Academy of Ophthalmology (AAO). Dry dye syndrome. Preferred Practice Pattern. San Francisco, CA: AAO; October 2013.
- Baer AN. Clinical manifestations of Sjögren's syndrome: Exocrine gland disease. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed May 2017b.
- Baer AN. Diagnosis and classification of Sjögren's syndrome. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed May 2017a.
- CGS Administrators, LLC. Billing and Coding: Ocular Photography - External. LCD Reference Article A57068. Medicare Administrative Contractor Parts A and B. Nashville, TN: CGS Administrators; revision effective May 9, 2024.
- Chaugule SS, Park J, Finger PT. Topical chemotherapy for giant ocular surface squamous neoplasia of the conjunctiva and cornea: Is surgery necessary? Indian J Ophthalmol. 2018;66(1):55-60.
- Dahl MV. Rosacea: Pathogenesis, clinical features, and diagnosis. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed June 2021.
- Donnenfeld ED, Perry HD, Gibralter RP, et al. Keratoconus associated with floppy eyelid syndrome. Ophthalmology. 1991;98(11):1674-1678.
- Ezra DG, Beaconsfield M, Collin R. Floppy eyelid syndrome: Stretching the limits. Surv Ophthalmol. 2010;55(1):35-46.
- Farrow A. Clinical ocular photography. Br J Ophthalmol. 2000;84(8):363G.
- Fogla R, Rao SK. Ophthalmic photography using a digital camera. Indian J Ophthalmol. 2003;51(3):269-272.
- Gurnani B, Kaur K. Ocular surface squamous neoplasia. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; updated July 31, 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK573082/. Accessed August 8, 2024.
- HealthNow UMD. Ocular photography, external. Contractor's Determination No. OP016E00. February 20, 2006.
- Knoop KJ. Slit lamp examination. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed July 2020.
- Lee CC, Lai HT, Kuo YR, et al. Floppy eyelid syndrome: An unfamiliar entity for plastic surgeons. Ann Plast Surg. 2018;80(2S Suppl 1):S40-S47.
- Maier LE. Management of rosacea. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed June 2021.
- Patel R, Patel BC. Dacryoadenitis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; updated May 24, 2022.
- Paysse EA, Coats DK, Cassidy M. Approach to the child with persistent tearing. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed June 2016.
- Rutar T, Youm J, Porco T, et al. Ophthalmic manifestations of perinatally acquired HIV in a US cohort of long-term survivors. Br J Ophthalmol. 2015;99(5):650-653.
- Safonova TN, Gladkova OV, Boev VI. Significance of laser confocal tomography in diagnosis and monitoring of keratoconjunctivitis sicca. Vestn Oftalmol. 2016;132(2):47-54.
- Saine PJ. Tutorial: External ocular photography. J Ophthalmic Photography. 2006;28(1):8-20.
- Schonberg S, Stokkermans TJ. Episcleritis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; updated March 16, 2022.
- Sun Y, Hua R. Ocular surface squamous neoplasia: Angiographic characteristics and response to subconjunctival/perilesional 5-fluorouracil injections. Drug Des Devel Ther. 2019;13:1323-1334.
