CurrentAetnaPolicy 0767

Extended Ophthalmoscopy

Customize your policy alerts

Sign up for Aetna Policy 0767 alerts

Get alerted when Policy 0767 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy governing medical necessity, coverage, and documentation requirements for extended ophthalmoscopy (detailed retinal drawing with interpretation) for evaluation of the posterior segment of the eye; applies to Aetna members and providers submitting claims to Aetna.

Policy Summary

PayerAetna

PolicyExtended Ophthalmoscopy

Policy CodePolicy 0767

Change TypeNo material changes

Effective DateAug 14, 2009

Last ReviewOct 26, 2023

Next Review DateAug 22, 2024

Key ActionObtain and document a detailed retinal drawing with interpretation when extended ophthalmoscopy is medically necessary and meets selection criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

28+

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy 0767

Extended Ophthalmoscopy

Customize your policy alerts

Sign up for Aetna Policy 0767 alerts

Get alerted when Policy 0767 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAetna

PolicyExtended Ophthalmoscopy

Policy CodePolicy 0767

Change TypeNo material changes

Effective DateAug 14, 2009

Last ReviewOct 26, 2023

Next Review DateAug 22, 2024

Key ActionObtain and document a detailed retinal drawing with interpretation when extended ophthalmoscopy is medically necessary and meets selection criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

28+

Medically necessary indications

17+Experimental indications

2.5in+Doc requirements

08/22/2024Next review

Coverage Criteria

Medical Necessity Indications

Covered when ANY of the following indications are present (extended ophthalmoscopy with a detailed retinal drawing is medically necessary following routine ophthalmoscopy):

Listed indications: 1. Blunt injury to the eye or periorbital structures; 2. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment; 3. Choroidal nevus being evaluated for malignant transformation; 4. Degenerative disorders of the globe; 5. Diabetic retinopathy (background or proliferative retinopathy, retinal vascular occlusion, or separation of the retinal layers); 6. Disorders of the vitreous body (e.g., vitreous hemorrhage or posterior vitreous detachment); 7. High axial length myopia (-6.00 D or less toward -10.00 D); 8. High-risk medication for retinopathy or optic neuropathy; 9. HIV retinopathy; 10. Macular degeneration; 11. Malignant neoplasm of the retina or choroid; 12. Metamorphopsia; 13. Optic atrophy associated with a progressive and potentially reversible cause (e.g., glaucoma); 14. Penetrating wound to the orbit resulting in retention of a foreign body in the eye; 15. Posterior scleritis; 16. Retained (old) intra-ocular foreign body (magnetic or non-magnetic); 17. Retinal defects without retinal detachment; 18. Retinal detachment (with or without defect); 19. Retinal edema; 20. Retinal hemorrhage, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration; 21. Retinopathy of prematurity; 22. Retinoschisis and retinal cysts; 23. Sudden or transient visual loss; 24. Suspected endophthalmitis (severe pain, redness, photophobia, profound vision loss); 25. Symptoms suggestive of retinal defect; 26. Systemic disorders associated with retinal pathology; 27. Uncontrolled glaucoma or glaucoma suspect; 28. Vogt-Koyanagi syndrome (bilateral uveitis, dysacousia, meningeal irritation, poliosis, vitiligo, and retinal detachment).

Must be based on routine ophthalmoscopy findings indicating need for more detailed study; extended ophthalmoscopy must add information not available from standard evaluation and should affect the treatment plan. Repeat exams are medically necessary only when signs, symptoms or condition change.

Experimental / Investigational (Not established effectiveness)

Considered experimental and investigational for the following indications:

Experimental indications: Congenital hypertrophy of the retinal pigment epithelium; Juvenile xanthogranuloma; Monitoring of fingolimod (Gilenya) therapy; Monitoring methotrexate or tamoxifen therapy; Monitoring individuals on checkpoint inhibitors (e.g., ipilimumab, nivolumab); Neurodegenerative disorders/diseases (e.g., Alzheimer's disease, amyotrophic lateral sclerosis, Friedreich's ataxia, Huntington's disease, Lewy body disease, multiple-system atrophy, Parkinson's disease, spinal muscular atrophy); Noonan's syndrome; Ophthalmic artery aneurysm; Optic neuritis; Peri-papillary atrophy; Pseudotumor cerebri (orbital pseudotumor); Retinal angioma; Retinochoroidal coloboma of iris; Screening for retinoblastoma; Sickle cell disease; Staphyloma posticum (posterior staphyloma); Surveillance of ocular melanoma in members with a history of cutaneous melanoma.

Listed examples where effectiveness has not been established and use is considered experimental/investigational.

Extended ophthalmoscopy is considered not medically necessary when the initial routine ophthalmoscopy showed normal clinical findings. The policy lists specific diagnostic examples and ICD-10 codes that are not covered for the indications in this Clinical Policy Bulletin, including conditions such as sickle-cell disease, optic neuritis, Noonan's syndrome, and other neurodegenerative or congenital conditions referenced in the ICD-10 lists.

When submitting claims, ensure the documented routine ophthalmoscopy findings support the need for extended ophthalmoscopy; absence of abnormal findings on the initial exam is a basis for denial per this policy.

Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and do not constitute a contract or an offer of coverage. They provide a partial, general description of plan or program benefits and may be updated. Participating providers remain responsible for treatment decisions and should consult the member's benefit plan and the Clinical Policy Bulletin Notes for any administrative details or coverage determinations.

Repeated extended ophthalmoscopy performed at each visit without any documented change in signs, symptoms, or clinical condition may be considered not medically necessary. Frequency of the service should be driven by medical necessity and whether sequential drawings will affect management.

Documentation supporting repeat exams must show interval change that would directly affect the treatment plan; otherwise repetition of an adequate prior drawing is not justified under this policy.

Coding

Covered CPT Codes, if selection criteria are metCPTCovered

92201	Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.
92202	Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.

ICD-10 codes covered if selection criteria are metICD-10

B20	Human immunodeficiency virus [HIV] disease
C69.20 - C69.32	Malignant neoplasm of retina or choroid
D31.30 - D31.32	Benign neoplasm of choroid [evaluation of choroidal nevus for malignant transformation]
E08.311 - E08.3559	Diabetes mellitus with ophthalmic complications (various subcodes listed)
E09.311 - E09.39	Drug or chemical induced diabetes mellitus (with ophthalmic complications)
E10.311 - E10.39	Diabetes mellitus with ophthalmic complications (type 1)
E11.311 - E11.39	Diabetes mellitus with ophthalmic complications (type 2)
E13.311 - E13.39	Diabetes mellitus due to underlying condition with ophthalmic complications
G45.3	Amaurosis fugax
H05.50 - H05.53	Retained (old) foreign body following penetrating wound of orbit

1–10 of 21

1/3

ICD-10 codes listed as not covered / experimental for CPB indicationsICD-10Not Covered

D18.09	Hemangioma of other sites [retina]
D57.00 - D57.1	Sickle-cell disease
D76.3	Other histiocytosis syndromes [juvenile xanthogranuloma]
G10	Huntington's chorea
G11.1	Early-onset cerebellar ataxia [Friedreich's ataxia]
G12.0 - G12.9	Spinal muscular atrophy and related syndromes
G20	Parkinson's disease
G23.0 - G23.9	Other degenerative diseases of basal ganglia
G30.0 - G30.9	Alzheimer's disease
G31.83	Dementia with Lewy bodies

1–10 of 17

1/2

Related LCDmixed

L25466

Medicare LCD reference for posterior segment imaging (extended ophthalmoscopy and fundus photography)

High axial length myopia — numeric threshold details (diopters)

Numeric threshold (diopters)High axial length myopia defined as -6.00 Diopters or less (toward -10.00 D).

Associated ICD-10 rangeH52.10 - H52.13 (Myopia) as listed for high axial length myopia.

Context for necessityListed as a covered indication when routine ophthalmoscopy findings warrant more detailed study.

Minimum drawing size — documentation requirement

Minimum drawing diameterRetinal drawing should be of sufficient size, usually no less than 2.5 inches in diameter.

Content requirements

Provider Actions & Requirements

Prior Authorization

Prior authorization requirement for CPT 92201 / 92202

CPT codes 92201 and 92202 are covered only when the policy selection criteria (medical necessity indications) are met — i.e., extended ophthalmoscopy is medically necessary for one or more listed indications following routine ophthalmoscopy.

Covered procedure codes: 92201 and 92202 (see CPT descriptions in policy).
Coverage requires that indications listed in the Medical Necessity section are present and documented.

Prior Authorization

Refer to Clinical Policy Bulletin for prior authorization guidance

Consult the Clinical Policy Bulletin notes and the policy review history for any prior authorization details and administrative updates related to code-level requirements.

Refer to the Clinical Policy Bulletin Notes link for administrative details.
Review the policy history (last review and effective dates) for recent changes that may affect prior authorization.

Background

Extended ophthalmoscopy is an examination of the posterior segment of the eye that provides a more detailed, documented view than routine ophthalmoscopy. It typically involves pharmacologic dilation and may use indirect ophthalmoscopy, scleral depression, or contact lens biomicroscopy to evaluate the optic disc, macula, retina, choroid and related structures.

This procedure includes a detailed retinal drawing with an interpretation and plan; the drawing should be anatomically specific, clearly labeled and of sufficient size (usually no less than 2.5 inches in diameter) to represent clinically significant findings that cannot be adequately communicated by text or other imaging alone. Extended ophthalmoscopy must add information not available from standard evaluation or other imaging studies and be expected to demonstrably affect the treatment plan.

Definitions

Extended ophthalmoscopy — definition and components

DefinitionExtended ophthalmoscopy is a method of examining and documenting the posterior portion of the eye (optic disk, arteries, veins, retina, choroid, media) with documentation greater than routine ophthalmoscopy.

Typical techniquesUsually performed with pharmacologic dilation and indirect ophthalmoscopy; may use contact lens biomicroscopy or scleral depression.

Scope of inspectionPermits visualization of the optic disk, retinal vessels, retina, choroid, and media to evaluate serious or suspected retinal conditions.

Extended ophthalmoscopy / posterior segment imaging — fundus photography and related definitions

Definition (posterior segment imaging)Extended ophthalmoscopy and fundus photography are imaging and examination techniques for posterior segment evaluation as referenced by AAO, AOA, and Medicare LCD L25466.

Policy Summary

PayerAetna

PolicyExtended Ophthalmoscopy

Policy CodePolicy 0767

Change TypeNo material changes

Effective DateAug 14, 2009

Last ReviewOct 26, 2023

Next Review DateAug 22, 2024

Key ActionObtain and document a detailed retinal drawing with interpretation when extended ophthalmoscopy is medically necessary and meets selection criteria.

SourceLink

On This Page

Drawing must be anatomically specific, clearly labeled, and accompanied by interpretation and plan (disc, macula or periphery).

Ancillary drawingsWhen defining optic nerve changes, ancillary cup-to-disc drawings (size, depth, rim, vessels, coloration) are required.

Note

Document medical necessity when billing extended ophthalmoscopy

Ensure documentation demonstrates that extended ophthalmoscopy was medically necessary for the member’s condition and that the service added information not available from standard evaluation or prior imaging.

Medical necessity must be based on routine ophthalmoscopy findings indicating need for more detailed study.
Do not bill extended ophthalmoscopy solely to confirm information already available from other tests.

Note

Check Clinical Policy Bulletin for administrative updates

Providers should consult the Clinical Policy Bulletin for administrative updates and note that the bulletin may be updated; maintain current awareness of any changes that could affect coverage or submission requirements.

Clinical Policy Bulletins may be updated and are the source for administrative details.
Keep documentation and billing practices aligned with the most recent bulletin version.

Documentation Required

Required documentation: detailed retinal drawing and report

Include a detailed retinal drawing (disc, macula or periphery) with interpretation and plan; the drawing must be anatomically specific, clearly labeled, and of sufficient size — usually no less than 2.5 inches in diameter.

Drawing must represent normal and abnormal findings and include ancillary cup-to-disc drawings when defining optic nerve changes.
Color coding is optional but if not used, a descriptive anatomy/pathology narrative is required.

Documentation Required

Clinical justification must show additive information

Document how extended ophthalmoscopy provided additive clinical information not available from standard evaluation or other imaging and how it affected the treatment plan.

Extended ophthalmoscopy must add information that will demonstrably affect the treatment plan.
When other imaging (e.g., fundus photography, fluorescein angiography, OCT, ultrasound) has been performed, document the reasonable expectation of additive non-duplicative information.

Note

Use Clinical Policy Bulletin for policy materials and updates

Providers should consult the Clinical Policy Bulletin Notes for administrative details and potential updates to policy materials; the bulletin is the reference for administering plan benefits.

Clinical Policy Bulletins are available via the policy’s Additional Information section.
Confirm bulletin updates before submitting claims or prior authorization requests.

Denial Risk

Denial risk for repeat exams without change

Repeatedly performing extended ophthalmoscopy at each visit without documented change in signs, symptoms, or condition risks denial as not medically necessary.

Frequency of service must be based on medical necessity and diagnosis; sequential drawings are appropriate only when they document clinically significant change.
If there is no change, the service may be considered not medically necessary.

Denial Risk

Denial risk when initial routine exam is normal

Extended ophthalmoscopy is considered not medically necessary when the initial routine ophthalmoscopy showed normal clinical findings; billing in that circumstance risks denial.

Ensure routine ophthalmoscopy findings indicate need for extended study before documenting and billing extended ophthalmoscopy.
If initial routine exam was normal, do not submit extended ophthalmoscopy as medically necessary.

Note

Administrative/legal note about Clinical Policy Bulletins

Clinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute offers of coverage or medical advice; providers remain responsible for treatment decisions and should note that the bulletin may be updated.

The bulletin contains only a partial description of benefits and is not a contract.
Providers are independent and responsible for medical advice and treatment decisions.

Medicare LCD No. L25466 cited for posterior segment imaging (extended ophthalmoscopy and fundus photography).

Use with other imagingExtended ophthalmoscopy is not necessary when other imaging has provided the required information unless additional non-duplicative information is expected.