Aetna considers retinopathy telescreening systems medically necessary as an alternative to screening performed by an ophthalmologist or optometrist for the purposes of screening for diabetic retinopathy and retinopathy of prematurity (ROP). However, these systems are experimental and investigational for uses including following the progression of disease in members who are diagnosed with diabetic retinopathy, and for screening or evaluation of retinal conditions other than diabetic retinopathy or ROP. Documentation that the use is for screening (not monitoring progression) is required for coverage of CPT codes 92227 and 92228 and HCPCS S3000 when selection criteria are met.

Use of retinopathy telescreening systems for screening for ROP is generally covered as an alternative to bedside ophthalmoscopic screening; however, screening by telescreening systems is not covered when the infant’s diagnosis includes codes for extremely low and other low birth weight newborns (P07.00 - P07.18).

Professional guidance cited in the policy indicates that telescreening should follow established ophthalmoscopic screening schedules and that at-risk infants should undergo indirect ophthalmoscopy by a qualified ophthalmologist at least once before initiating treatment or terminating screening, reinforcing that telescreening does not replace necessary in-person examinations.

Findings from a pilot study comparing RetCam digital retinal imaging to indirect ophthalmoscopy showed a sensitivity of 85% and specificity of 35% for detection of referral-warranted ROP. The study authors concluded that, based on these results, digital imaging cannot be proposed as a substitute for indirect ophthalmoscopy and that further study with more patients and graders is needed.

Retinopathy telescreening systems are explicitly listed as not medically necessary for monitoring the progression of diabetic retinopathy in members already diagnosed with diabetic retinopathy. Such use is considered experimental/investigational because evidence of clinical value for disease monitoring is insufficient.

Diabetic retinopathy is a common, potentially vision‑threatening complication of diabetes with prevalence related to duration of disease; timely detection allows interventions (for example, laser photocoagulation) to reduce the risk of vision loss. Retinopathy telescreening systems capture retinal images in non‑ophthalmology settings and transmit them to remote readers for evaluation; multiple validation studies report high sensitivity and specificity for screening diabetic retinopathy compared with standard methods. For retinopathy of prematurity, telemedicine using wide‑field imaging (for example, RetCam) has demonstrated diagnostic accuracy in several programs, but bedside indirect ophthalmoscopy remains the reference standard and should not be routinely replaced by imaging alone.