CurrentAetnaPolicy 0689

Ocular Photoscreening

Defines Aetna's medical necessity and investigational positions for ocular photoscreening and retinal birefringence scanning for detection of amblyogenic risk factors and strabismus in pediatric populations; lists applicable CPT/HCPCS and ICD-10 codes and summarizes evidence/background.

Policy Summary

PayerAetna

PolicyOcular Photoscreening

Policy CodePolicy 0689

Change TypeNo material change

Effective DateAug 13, 2004

Next Review DateJul 25, 2024

Key ActionDocument medical necessity per criteria: one ocular photoscreening is medically necessary for children age 3, and for children 4–5 years unable to cooperate with routine acuity testing; use covered CPT codes 99174 or 99177 when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — has_material_change=false.

1Allowed photoscreenings per child age 3

conditionalAllowed for children 4-5 years

2004Policy effective

Coverage Summary

This policy addresses Aetna's positions on ocular photoscreening for children and on retinal birefringence scanning (RBS). Photoscreening uses a specialized camera or video system to obtain images of pupillary and red reflexes to detect amblyogenic risk factors (such as strabismus, media opacities, and significant refractive errors); an evaluator, reviewing center, or computer analyzes the data and children with abnormal findings are referred for a complete eye examination.

Aetna considers one ocular photoscreening medically necessary for all children 3 years of age, and medically necessary for children 4 to 5 years of age who are unable to cooperate with routine acuity screening (for example, intellectual disability, developmental delay, or severe behavioral disorders). The policy notes that photoscreening is especially useful in preverbal or developmentally delayed children who cannot cooperate with standard acuity testing.

The U.S. Preventive Services Task Force (USPSTF) recommends vision screening at least once between ages 3 and 5 years to detect amblyopia or its risk factors and concluded that evidence is insufficient to assess the balance of benefits and harms of vision screening for children younger than 3 years. Aetna considers retinal birefringence scanning (RBS) experimental and investigational because its effectiveness has not been established.

Medical Necessity & Not Medically Necessary Criteria

Medically Necessary

Aetna considers one ocular photoscreening medically necessary when ALL of the following are met:

ALL of the following

Patient is a child 3 years of age (one screening permitted)
ONE of: OR patient is a child 4 to 5 years of age who is unable to cooperate with routine acuity screening (e.g., intellectual disability, developmental delay, severe behavioral disorders)

ref Making sure to echo the block's ref EXACTLY: b1_0

title Please provide the group's title exactly as specified: Medically Necessary

Experimental and Investigational / Not Medically Necessary

Aetna considers the following experimental and investigational because effectiveness has not been established:

Retinal birefringence scanning for the detection of eye misalignment or strabismus

Examples include Pediatric Vision Scanner (PVS) and similar RBS devices

Applicable Codes

Covered CPT codes when selection criteria are metCPTCovered

99174	Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report
99177	Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis

Not covered CPT / HCPCS codes for indications listed in CPBHCPCSNot Covered

0469T

Retinal polarization scan, ocular screening with on-site automated results, bilateral

ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10Covered

H52.00-H52.7	Disorders of refraction and accommodation
H53.001-H54.8	Visual disturbances, blindness and low vision
P07.00-P07.32	Disorders of newborn related to short gestation and low birth weight, not elsewhere classified
Z00.129	Encounter for routine child health examination without abnormal findings
Z01.00-Z01.01	Encounter for examination of eyes and vision
Z02.0-Z02.3,Z02.89	Encounter for administrative examination
Z13.5	Encounter for screening for eye and ear disorders

ICD-10 codes not covered for indications listed in CPBICD-10Not Covered

H49.00-H49.9	Paralytic strabismus
H50.00-H50.9	Other strabismus
Z00.110-Z00.129	Encounter for newborn, infant and child health examinations
Z01.00-Z01.01	Encounter for examination of eyes and vision

Provider Actions & Billing Guidance

Prior Authorization

Prior authorization for photoscreening

Document medical necessity per the policy: one ocular photoscreening is medically necessary for children age 3, and for children 4–5 years who cannot cooperate with routine acuity testing. Use the covered CPT codes when criteria are met.

99174
99177

Denial Risk

Risk of denial for retinal birefringence scanning

Claims for retinal birefringence scanning (RBS) for detection of strabismus or eye misalignment are considered experimental/investigational and are not covered; expect claim denial.

0469T — expect denial

Documentation Required

Document indication and cooperation status

Maintain documentation of the patient's age and specific evidence that a 4–5 year old is unable to cooperate with routine acuity screening to justify photoscreening.

Intellectual disability
Developmental delay
Severe behavioral disorders

Background & Evidence

Photoscreening is used to screen for amblyogenic factors and has an advantage over standard methods because it requires minimal cooperation from the child, making it particularly useful for preverbal, preliterate, or developmentally delayed children who cannot provide subjective responses to visual acuity testing or cooperate with ocular alignment/stereoacuity testing.

The USPSTF recommendation states vision screening should be performed at least once between ages 3 and 5 years, and the USPSTF found the evidence insufficient to assess benefits and harms of screening in children younger than 3 years. The AAP and related organizations have noted that instrument-based screening (including photoscreening) may be electively performed in children to age 3 and in older children unable to cooperate with routine acuity testing.

Regarding retinal birefringence scanning (RBS), current evidence is insufficient to establish its clinical value; Aetna considers RBS experimental and investigational for detection of eye misalignment or strabismus because effectiveness has not been established, and systematic reviews have called for larger, well-designed studies to determine its value.