RELATED MEDICAL POLICIES/GUIDELINES: None. Select a hyperlink below to be directed to that section.

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1 UTILIZATION MANAGEMENT GUIDELINE Fundus Photography Effective Date: June 1, 2018 Last Revised: May 3, 2018 Replaces: N/A RELATED MEDICAL POLICIES/GUIDELINES: None Select a hyperlink below to be directed to that section. COVERAGE GUIDELINE DOCUMENTATION REQUIREMENTS CODING RELATED INFORMATION EVIDENCE REVIEW REFERENCES HISTORY Clicking this icon returns you to the hyperlinks menu above. Introduction The fundus of the eye is the back of the inner eye. Fundus photography uses a microscope with an attached camera to take a digital photograph of this area. The photo captures images of structures such as the retina (that converts light into signals the brain can understand), the optic nerve (that sends the signals to the brain), and the macula (allows a person to have sharp, clear vision straight ahead). Fundus photography is most useful when a disease is suspected or a condition needs to be monitored. It s also useful to see if the retina has been damaged after eye trauma or injury. Fundus photography is unnecessary when a routine eye exam does not indicate any eye problems or symptoms. This policy describes when fundus photography may be considered medically necessary. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. Coverage Guideline

2 Medical Necessity Fundus Photography may be considered medically necessary to evaluate abnormalities in the fundus of the eye, follow the progression of a known disease or evaluate the response to treatment of an eye injury. Indications that may need examination or monitoring include, but are not limited to the following: Abnormal electro-oculogram (EOG) or oculomotor studies Abnormal retinal function studies Abnormal visually evoked potential Age-related macular degeneration Anti-malarial therapy (Plaquenil or hydroxychloroquine or Aralen or chloroquine) when fundus changes are noted during standard screening o For example, automated threshold visual field testing, optical coherence tomography, fundus auto fluorescence imaging, multifocal electro-retinogram (Note: Drug may also be taken for treatment of rheumatoid arthritis or lupus) Autoimmune disease involving the eye o For example, systemic lupus erythematosus, rheumatoid arthritis and other inflammatory polyarthropathies Choroid disorders (for example, chorioretinal inflammation) Color vision deficiency Suspected congenital anomalies of the posterior segment of the eye Diabetic retinopathy Glaucoma Glaucoma suspected/pre-glaucoma when consistently elevated intraocular pressure is documented Infection of the eye o For example, endophthalmitis, histoplasmosis, human immunodeficiency virus (HIV), syphilis, cytomegalovirus, congenital rubella, toxoplasmosis Neoplasm of the choroid, cranial nerves, eyeball or retina Ocular trauma or foreign body in the eye Optic nerve disorders o For example, multiple sclerosis Pseudotumor cerebri (high pressure within the skull for no apparent reason) Retinal detachment and retinal defects Retinal abnormalities when the study results will change the treatment plan Retinopathy of prematurity (ROP) for infants less than 1500 grams or born at 30 weeks gestation or less Page 2 of 8

3 Medical Necessity Sickle-cell anemia Tuberous sclerosis Visual field exam abnormality when the study results will change the treatment plan Fundus photography is considered not medically necessary when the routine ophthalmology (eye) exam shows normal clinical findings. Fundus photography is considered not medically necessary when no symptoms are present. Fundus photography is considered not medically necessary to routinely screen for eye (ocular) disorders. Remote imaging used to detect retinal disease is considered screening. Documentation Requirements The medical records submitted for review should document that medical necessity criteria are met. Include detailed history and physical supporting eyes abnormalities or a known condition that needs to be monitored or to follow up the response to treatment of an eye injury. Coding Code Descriptor CPT Fundus photography with interpretation and report ICD-10 Diagnosis Codes - Covered A50.01 Early congenital syphilitic oculopathy A50.30 Late congenital syphilitic oculopathy, unspecified A50.44 Late congenital syphilitic optic nerve atrophy A51.43 Secondary syphilitic oculopathy A52.15 Late syphilitic neuropathy A52.71 Late syphilitic oculopathy B20 Human immunodeficiency virus [HIV] disease Page 3 of 8

4 Code Descriptor B25.0 B25.9 Cytomegaloviral disease B39.4 B39.9 Histoplasmosis B50.0 B52.9 Malaria B58.00 B58.09 Toxoplasma oculopathy C69.00 C69.92 Malignant neoplasm of eye and adnexa C79.49 Secondary malignant neoplasm of other parts of nervous system D09.20 D09.22 Carcinoma in situ of eye D31.00 D31.92 Benign neoplasm of eye and adnexa D33.3 Benign neoplasm of cranial nerves D49.81 Neoplasm of unspecified behavior of retina and choroid D57.00 D Sickle-cell disorders E08.00 E11.9 Diabetes mellitus E70.20 E70.9 Disorders of aromatic amino-acid metabolism G35 Multiple sclerosis G93.2 Benign intracranial hypertension H27.10 H Subluxation of lens H H Posterior dislocation of lens H H30.93 Chorioretinal inflammation H31.00 H31.9 Other diseases of choroid H32 Chorioretinal disorders in diseases classified elsewhere H H33.8 Retinal detachment and breaks H34.00 H34.9 Retinal vascular occlusions H35.00 H35.9 Other retinal disorders H36 Retinal disorders in diseases classified elsewhere H H40.9 Glaucoma H42 Glaucoma in diseases classified elsewhere Page 4 of 8

5 Code Descriptor H43.00 H43.9 Disorders of vitreous body H H44.9 Disorders of globe H46.00 H47.9 Disorders of optic nerve and visual pathways H53.50 H53.59 Color vision deficiencies H H Cystoid macular edema following cataract surgery L93.0 L93.2 Lupus erythematosus M05.00 M14.89 Rheumatoid arthritis and inflammatory polyarthropathies M32.0 M32.9 Systemic lupus erythematosus (SLE) M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis P35.0 P35.9 Congenital viral diseases P37.0 P37.9 Other congenital infectious and parasitic diseases Q13.4 Other congenital corneal malformations Q14.0 Q14.9 Congenital malformations of posterior segment of eye Q15.0 Congenital glaucoma Q85.1 Tuberous sclerosis Q85.8 Q85.9 Other and unspecified phakomatoses, not elsewhere classified Q87.1 Q87.89 Other specified congenital malformation syndromes affecting multiple systems Q89.8 Other specified congenital malformations Q99.2 Fragile X chromosome R R Abnormal results of function studies of eye S05.00XA S05.92XS Injury of eye and orbit Z Other long term (current) drug therapy Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS). Page 5 of 8

6 Related Information In order to be a covered service, the results from fundus photography must have a direct impact on the decision-making related to the patient s medical care and treatment. In general, fundus photographs are not needed to confirm the presence of a condition, but are necessary in determining the progression of a known disease that affects the eye. The term retinal fundus means the inside or back of the eyeball that is seen through the pupil during a dilated eye examination. Fundus photography uses a special camera to photograph structures behind the lens of the eye including the choroid, optic nerve, retina and vitreous. The image can be either digital or a hard copy photograph. Fundus photography is used to evaluate and document vascular and structural changes related to eye conditions not part of a routine screening eye examination. Some of these conditions include choroid disturbances, diabetic retinopathy, glaucoma, macular degeneration, multiple sclerosis or other central nervous system abnormalities, and tumors of the retina. A comprehensive eye examination includes evaluation of any signs and symptoms present at the time of the office visit. Signs and symptoms involving the eye can be divided into three basic categories: abnormalities of vision, abnormalities of eye appearance, and abnormalities of eye feelings/sensation such as pain and discomfort. Patients without any signs or symptoms should not have routine imaging studies of their eyes if the only goal is to document normal eye anatomy. (See Practice Guidelines and Position Statements directly below.) Evidence Review Practice Guidelines and Position Statements American Academy of Ophthalmology (AAO) The AAO recommends against imaging tests for patients without symptoms or signs of significant eye disease. In their statement for ChoosingWisely they say the following: Page 6 of 8

7 If patients do not have symptoms or signs of significant disease pathology, then clinical imaging tests are not generally needed because a comprehensive history and physical examination will usually reveal if eye disease is present or is getting worse. Examples of routine imaging include: visual-field testing; optical coherence tomography (OCT) testing; retinal imaging of patients with diabetes; and neuroimaging or fundus photography. If symptoms or signs of disease are present, then imaging tests may be needed to evaluate further and to help in treatment planning. Available at URL: Accessed May All AAO Preferred Practice Pattern (PPP) guidelines are available at: Accessed May Institute for Clinical Systems Improvement (ICSI) The ICSI guideline for Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults recommends the following: A dilated eye examination for diabetic eye disease performed by an ophthalmologist or optometrist is recommended annually for patients with T2DM. Less frequent exams (every two to three years) may be considered in the setting of a normal eye exam. The role of fundus photography is still being considered, but does not replace a comprehensive exam. Available at URL: Accessed May References 1. Marmor MF, Kellner U, Lai TY, et al. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011; 118(2): Page 7 of 8

8 History Date Comments 04/01/16 New UM Guideline, approved March 8, Add to Vision section. Fundus photography may be considered medically necessary for the indications listed in the guideline. Routine fundus photography or for asymptomatic patients is not medically necessary because it is not clinically indicated based on the specialty practice guidelines. This policy will be effective August 1, 2016, following 90-day provider notification. 07/01/16 Interim Review, approved June 14, Policy updated to indicate screening for eye (ocular) disorders as not medically necessary; previously listed as investigational. CPT codes removed with the exception of /01/17 Annual Review, approved January 10, Added clarification that glaucomasuspected/pre-glaucoma is evidenced by abnormal results from the usual screening test for glaucoma. Indications simplified and put in alphabetical order. Practice Guideline added from the ICSI added. 07/01/17 Annual Review, approved June 6, Policy updated with literature review. Clarifying edits made to policy section. Investigational policy statement removed; The intent of this policy is medically necessary when criteria are met, not medically necessary when criteria are not met. Clarified Plaquenil as anti-malarial drug. 08/15/17 Updated Coding table to include covered diagnosis codes and code ranges. 06/01/18 Annual Review, approved May 3, Medical necessity statements edited for clarity. Intent did not change. Reference 1 added. Otherwise policy statements unchanged. Added diagnosis codes M35.00, M35.01, and Q15.0 to policy. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Page 8 of 8

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10 日本語 (Japanese): この通知には重要な情報が含まれています この通知には LifeWise Assurance Company の申請または補償範囲に関する重要な情報が含まれている場合があります この通知に記載されている可能性がある重要な日付をご確認ください 健康保険や有料サポートを維持するには 特定の期日までに行動を取らなければならない場合があります ご希望の言語による情報とサポートが無料で提供されます (TTY: ) までお電話ください 한국어 (Korean): 본통지서에는중요한정보가들어있습니다. 즉이통지서는귀하의신청에관하여그리고 LifeWise Assurance Company 를통한커버리지에관한정보를포함하고있을수있습니다. 본통지서에는핵심이되는날짜들이있을수있습니다. 귀하는귀하의건강커버리지를계속유지하거나비용을절감하기위해서일정한마감일까지조치를취해야할필요가있을수있습니다. 귀하는이러한정보와도움을귀하의언어로비용부담없이얻을수있는권리가있습니다 (TTY: ) 로전화하십시오. ລາວ (Lao): ແຈ ງການນ ມ ຂ ມ ນສ າຄ ນ. ແຈ ງການນ ອາດຈະມ ຂ ມ ນສ າຄ ນກ ຽວກ ບຄ າຮ ອງສະ ໝ ກ ຫ ຄວາມຄ ມຄອງປະກ ນໄພຂອງທ ານຜ ານ LifeWise Assurance Company. ອາດຈະມ ວ ນທ ສ າຄ ນໃນແຈ ງການນ. ທ ານອາດຈະຈ າເປ ນຕ ອງດ າເນ ນການຕາມ ກ ານ ດເວລາສະເພາະເພ ອຮ ກສາຄວາມຄ ມຄອງປະກ ນສ ຂະພາບ ຫ ຄວາມຊ ວຍ ເຫ ອເລ ອງຄ າໃຊ ຈ າຍຂອງທ ານໄວ. ທ ານມ ສ ດໄດ ຮ ບຂ ມ ນນ ແລະ ຄວາມຊ ວຍເຫ ອ ເປ ນພາສາຂອງທ ານໂດຍບ ເສຍຄ າ. ໃຫ ໂທຫາ ភ ស ខមរ (Khmer): សចកត ជ នដ ណ ង ន ម នព ត ម នយ ងស ខ ន សចកត ជ នដ ណ ង ន រប ហល ជ ម នព ត ម នយ ងស ខ ន អ ព ទរមង បបបទ ឬក ររ ប រងរបស អនកត មរយ LifeWise Assurance Company រប ហលជ ម ន ក លបរ ចឆទស ខ ន ន កន ង សចកត ជ នដ ណ ង ន អនករប ហលជ រត វក រប ញច ញសមតថភ ព ដល ក ណត ថង ជ ក ចប ស ន ន ដ មប ន ងរកស ទ កក រធ ន រ ប រងស ខភ ពរបស អនក ឬរប ក ជ ន យ ចញ ថល អនកម នស ទធ ទទ លព ត ម ន ន ន ងជ ន យ ន កន ងភ ស របស អនក ដ យម នអសល យ ឡ យ ស មទ រស ពទ (TTY: ) ਪ ਜ ਬ (Punjabi): ਇਸ ਨ ਟਸ ਵਚ ਖ ਸ ਜ ਣਕ ਰ ਹ. ਇਸ ਨ ਟਸ ਵਚ LifeWise Assurance Company ਵਲ ਤ ਹ ਡ ਕਵਰ ਜ ਅਤ ਅਰਜ ਬ ਰ ਮਹ ਤਵਪ ਰਨ ਜ ਣਕ ਰ ਹ ਸਕਦ ਹ. ਇਸ ਨ ਜਸ ਜਵਚ ਖ ਸ ਤ ਰ ਖ ਹ ਸਕਦ ਆ ਹਨ. ਜ ਕਰ ਤ ਸ ਜਸਹਤ ਕਵਰ ਜ ਰ ਖਣ ਹ ਵ ਜ ਓਸ ਦ ਲ ਗਤ ਜ ਵ ਚ ਮਦਦ ਦ ਇਛ ਕ ਹ ਤ ਤ ਹ ਨ ਅ ਤਮ ਤ ਰ ਖ਼ ਤ ਪ ਹਲ ਕ ਝ ਖ ਸ ਕਦਮ ਚ ਕਣ ਦ ਲ ੜ ਹ ਸਕਦ ਹ,ਤ ਹ ਨ ਮ ਫ਼ਤ ਵ ਚ ਤ ਆਪਣ ਭ ਸ਼ ਵ ਚ ਜ ਣਕ ਰ ਅਤ ਮਦਦ ਪ ਰ ਪਤ ਕਰਨ ਦ ਅ ਧਕ ਰ ਹ,ਕ ਲ (Farsi): فارسی اين اعالميه حاوی اطالعات مھم ميباشد.اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم تقاضا و يا پوشش بيمه ای شما از طريق LifeWise Assurance Company باشد. به تاريخ ھای مھم در اين اعالميه توجه نماييد.شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه ھای درمانی تان به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد.شما حق اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد. برای کسب اطالعات با شماره (کاربران TTY تماس باشماره ) تماس برقرار نماييد. Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez LifeWise Assurance Company. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do LifeWise Assurance Company. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Assurance Company. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через LifeWise Assurance Company. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону Fa asamoa (Samoan): Atonu ua iai i lenei fa asilasilaga ni fa amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa asilasilaga o se fesoasoani e fa amatala atili i ai i le tulaga o le polokalame, LifeWise Assurance Company, ua e tau fia maua atu i ai. Fa amolemole, ia e iloilo fa alelei i aso fa apitoa olo o iai i lenei fa asilasilaga taua. Masalo o le a iai ni feau e tatau ona e faia ao le i aulia le aso ua ta ua i lenei fa asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo o e iai i ai. Olo o iai iate oe le aia tatau e maua atu i lenei fa asilasilaga ma lenei fa matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Assurance Company. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng LifeWise Assurance Company. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa ไทย (Thai): ประกาศน ม ข อม ลส าค ญ ประกาศน อาจม ข อม ลท ส าค ญเก ยวก บการการสม ครหร อขอบเขตประก น ส ขภาพของค ณผ าน LifeWise Assurance Company และอาจม ก าหนดการในประกาศน ค ณ อาจจะต องด าเน นการภายในก าหนดระยะเวลาท แน นอนเพ อจะร กษาการประก นส ขภาพของค ณหร อการ ช วยเหล อท ม ค าใช จ าย ค ณม ส ทธ ท จะได ร บข อม ลและความช วยเหล อน ในภาษาของค ณโดยไม ม ค าใช จ าย โทร (TTY: ) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через LifeWise Assurance Company. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình LifeWise Assurance Company. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số