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Endothelial Cell Photography
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This policy governs when endothelial cell photography (specular endothelial microscopy) is considered medically necessary or investigational for Aetna members. It affects ophthalmologists, optometrists, and other providers ordering or billing for endothelial cell photography.
No material clinical or coverage changes in this revision.
Coverage Criteria for Endothelial Cell Photography
Medical Necessity — Covered when ANY of the following are met
Covered when ANY of the following are met
Each numbered item is an independent indication; presence of any one supports medical necessity.
Experimental and Investigational — Not covered / investigational for other indications
Not covered / investigational for other indications
Requests outside the listed indications are considered investigational and may be denied.
Endothelial cell photography performed prior to cataract surgery is considered part of the pre-surgical comprehensive or brief/intermediate eye examination when the member’s only visual problem is cataracts and therefore should not be billed separately in that context. This applies regardless of the cataract technique used (including phaco-emulsification). Use of endothelial cell photography as a preoperative assessment is intended to document corneal endothelial status to help predict surgical risk and guide perioperative management.
Use of endothelial cell photography for indications other than the specific situations listed in this policy is considered not medically necessary/experimental and investigational because it has not been shown to have proven clinical value for other indications.
Coding (CPT and Diagnosis Codes)
| H18.10-H18.239 | Bullous keratopathy and other and unspecified corneal edema (ICD-10 range shown as examples of covered diagnoses). |
| H18.51 | Endothelial corneal dystrophy. |
| H18.59 | Other hereditary corneal dystrophies. |
Provider Requirements and Prior Authorization
Clinical Indication Documentation
Documentation supporting the medical necessity decision must be included with the request.
- Include clinical history and reason for test (see allowed indications).
- Provide prior operative notes or planned procedure details when testing is pre‑operative.
Indication Verification Required
Requests for CPT 92286 must document that the member meets one of the medically necessary indications (see policy).
- Examples of qualifying indications: preoperative evaluation for extended‑wear contact lenses after intraocular surgery; planned secondary intraocular lens implantation; planned surgery with increased risk to corneal endothelium; prior intraocular surgery and planned cataract surgery; slit‑lamp evidence of corneal edema; slit‑lamp evidence of endothelial dystrophy (corneal guttata/Fuchs'); posterior polymorphous dystrophy or irido‑corneal endothelium syndrome.
Denial Risk for Non‑enumerated Indications
Requests for endothelial cell photography for indications not listed as medically necessary will be considered investigational and are subject to denial.
- Requests for other indications (not enumerated in policy) will be denied as experimental/investigational.
- Ensure documentation clearly matches one of the listed medically necessary indications to avoid denial risk.
Background
Endothelial cell photography, also known as specular endothelial microscopy or anterior segment photography, uses a specular microscope to image the corneal endothelium and determine endothelial cell count. It is used by ophthalmologists to assess corneal endothelial status and help predict the likelihood of surgical success or increased risk to the corneal endothelium prior to ocular procedures.
Definitions
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