CurrentAmbetter NevadaPolicy CP.VP.26

Extended Ophthalmoscopy

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.VP.26 alerts

Get alerted when Policy CP.VP.26 changes without checking for updates manually.

Monitor payer policy activity

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

Medical necessity and coding guidance for extended ophthalmoscopy (detailed posterior segment retinal exam with drawing and report) for members of Ambetter Nevada / Centene-affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyExtended Ophthalmoscopy

Policy CodePolicy CP.VP.26

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionSupport claims for CPT 92201 and 92202 with a detailed, anatomically specific retinal drawing (≥3–4 inches), interpretation and report documenting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CPT codes referenced

multiple

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.

CurrentAmbetter NevadaPolicy CP.VP.26

Extended Ophthalmoscopy

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.VP.26 alerts

Get alerted when Policy CP.VP.26 changes without checking for updates manually.

Monitor payer policy activity

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

Medical necessity and coding guidance for extended ophthalmoscopy (detailed posterior segment retinal exam with drawing and report) for members of Ambetter Nevada / Centene-affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyExtended Ophthalmoscopy

Policy CodePolicy CP.VP.26

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionSupport claims for CPT 92201 and 92202 with a detailed, anatomically specific retinal drawing (≥3–4 inches), interpretation and report documenting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CPT codes referenced

multiple

Coverage Criteria

Medical necessity — indications

Covered when ANY of the following indications are present:

Covered indications: Infants undergoing treatment and/or monitoring of retinopathy of prematurity; Histoplasmosis; Choroidal neoplasms; Glaucoma; Optic nerve pathology; Diabetic retinopathy; Hypertensive retinopathy; Vascular occlusion; Retinal neovascularization; Macular pathology; Retinal tear, thinning, schisis or detachment; Hereditary retinal dystrophies; Other visible retinal disorders requiring detailed imaging for adequate documentation.

From policy section I.A–M.

Not medically necessary

Not medically necessary when ANY of the following apply:

Not medically necessary conditions: Routine replacement of standard ophthalmoscopy with extended ophthalmoscopy to document the appearance of healthy retinal anatomy; Duplicative documentation of retinal pathology with extended ophthalmoscopy in conjunction with fundus photography, fluorescein angiography, or other imaging unless the additional diagnostic procedures provide new information to assist in clinical decision-making; Repeated performance in the presence of controlled and/or stable disease.

From policy section II.A–C.

Extended ophthalmoscopy should not be used as a routine replacement for standard ophthalmoscopy, nor as a duplicative test when other imaging already documents pathology without providing additional clinical information. The policy specifies that extended ophthalmoscopy is not medically necessary when it is performed merely to document healthy retinal anatomy, when it duplicates fundus photography/fluorescein angiography (unless new information is generated to affect clinical decisions), or when it is repeatedly performed for controlled or stable disease.

The policy provides an extensive list of ICD-10 diagnosis codes that support the use of extended ophthalmoscopy; the excerpted segment reproduces multiple diabetes-related and retinal diagnosis codes used to justify the procedure but does not state additional explicit exclusions in this listing.

This document segment contains a continued listing of ICD-10 diagnoses (retinal vascular and vein/artery occlusion codes, venous engorgement, tributary retinal vein occlusion subtypes, etc.) relevant to extended ophthalmoscopy coverage; no standalone coverage statements are included in this excerpt.

Coverage of extended ophthalmoscopy is governed by the member's plan documents and applicable legal/regulatory requirements. The policy is a guide to medical necessity but does not replace the coverage terms, conditions, exclusions and limitations in the member's contract; for Medicaid members, state Medicaid provisions take precedence when conflicts exist, and Medicare NCDs/LCDs should be reviewed for Medicare members.

The policy reiterates that extended ophthalmoscopy is not medically necessary when used for routine replacement of standard ophthalmoscopy or when it provides duplicative documentation without adding new clinical information; these situations are specifically listed as examples that may lead to noncoverage or denial.

The ICD-10 code listings in this coverage excerpt are presented without explicit statements in this segment declaring procedures not medically necessary; the excerpt functions as a supporting diagnosis list rather than a full coverage rationale in this passage.

The continued diagnostic code excerpt lists retinal vascular and related ICD-10 codes but does not itself include discrete determinations that any use of extended ophthalmoscopy is not medically necessary; it is a code reference section in the policy.

Coding and Diagnosis Codes

Covered CPT CodesCPTCovered

92201	Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease with interpretation and report, unilateral or bilateral.
92202	Ophthalmoscopy, extended; with drawing of optic nerve or macula with interpretation and report, unilateral or bilateral.

ICD-10-CM Diagnosis Codes that Support Coverage Criteria (selected list)ICD-10

H59.022	Cataract (lens) fragments in eye following cataract surgery, left eye.
H59.023	Cataract (lens) fragments in eye following cataract surgery, bilateral.
H59.031	Cystoid macular edema following cataract surgery, right eye.
H59.032	Cystoid macular edema following cataract surgery, left eye.
H59.033	Cystoid macular edema following cataract surgery, bilateral.
P07.17	Other low birth weight newborn, 1750-1999 grams.
P07.22	Extreme immaturity of newborn, gestational age 23 completed weeks.
P07.23	Extreme immaturity of newborn, gestational age 24 completed weeks.
P07.24	Extreme immaturity of newborn, gestational age 25 completed weeks.
P07.25	Extreme immaturity of newborn, gestational age 26 completed weeks.

1–10 of 32

1/4

Injury and Trauma ICD-10 Codes (selected ocular trauma codes)ICD-10

S05.11XA	Contusion of conjunctiva and corneal abrasion, right eye, initial encounter (example - ocular trauma).
S05.11XD	... subsequent encounter.
S05.11XS	... sequela.
S05.12XA	Contusion of conjunctiva and corneal abrasion, left eye, initial encounter.
S05.12XD	... subsequent encounter.
S05.12XS	... sequela.
S05.21XA	Other superficial injury of eye and orbit, right eye, initial encounter.
S05.21XD	... subsequent encounter.
S05.21XS	... sequela.
S05.22XA	Other superficial injury of eye and orbit, left eye, initial encounter.

1–10 of 36

1/4

Abuse/Neglect/Device Complication CodesICD-10

T74.4XXA	Adult sexual abuse, confirmed, initial encounter (placeholder example for abuse coding).
T74.4XXD	... subsequent encounter.
T74.4XXS	... sequela.
T85.22XA	Mechanical complication of ophthalmic device or graft, initial encounter.
T85.22XD	... subsequent encounter.
T85.22XS	... sequela.

Provider Actions and Documentation Requirements

Prior Authorization

Provider Actions and Documentation Requirements

Prior authorization may be required; providers should verify prior authorization and coverage under the member contract and applicable state and federal law prior to performing extended ophthalmoscopy. Claims for CPT 92201 and 92202 should be supported by documentation that meets this policy's medical necessity requirements and the drawing/report requirement described below. Extended ophthalmoscopy must include an anatomically specific, clearly labeled retinal drawing (disc, macula, or periphery as applicable) of sufficient size (minimum ~3-4 inches diameter), interpretation, and a report. Providers are expected to document medical necessity consistent with this clinical policy and their professional judgment. Where the policy does not specify explicit denial triggers or prior authorization processes in these excerpts, no additional explicit authorization or denial triggers are stated here; however, claims may still be denied if they duplicate documentation, are routine replacements of standard ophthalmoscopy, fail to meet the drawing/report requirements, or do not adhere to the member contract, state or federal rules, or plan exclusions.

Verify prior authorization and member coverage before scheduling extended ophthalmoscopy.
Ensure claims for CPT 92201 and 92202 are supported by medical necessity documentation and the required retinal drawing and report.
Include an anatomically specific, clearly labeled drawing (disc, macula, or periphery) of sufficient size (~3-4 inches diameter), interpretation, and report in the medical record.
Document clinical indications consistent with the policy (e.g., diabetic retinopathy, retinal tear/detachment, macular pathology, optic nerve pathology, etc.) and code to the specific ICD-10 diagnosis.

Background

Extended ophthalmoscopy is a detailed posterior segment examination performed, typically after pharmacologic pupil dilation, using indirect ophthalmoscopy or contact-lens biomicroscopy and, when required, scleral depression to visualize the peripheral retina. The procedure includes creation of a detailed, anatomically specific retinal drawing and a written interpretation/report, and is used when a complete view of the optic disc, macula, vessels, retina, choroid and vitreous is necessary to evaluate or document posterior segment pathology.

Definitions

Extended ophthalmoscopy — definition

Core definitionDetailed posterior segment examination including a retinal drawing, interpretation and report, often performed with pupil dilation and indirect ophthalmoscopy (may include contact lens biomicroscopy and scleral depression).

Documentation requirementDrawing must be anatomically specific, clearly labeled, and of sufficient size (no less than 3-4 inches in diameter) with interpretation and report.

Examination componentsVisualization and documentation of optic disc, macula, vessels, retina, choroid and vitreous; may require peripheral (scleral-depressed) views.

Purpose / useUsed when a more detailed examination than routine ophthalmoscopy is needed to evaluate posterior segment pathology and provide precise documentation.

Extended Ophthalmoscopy — title/label

Policy title reference

Revision History

The policy record notes an original approval in 01/2020 and includes review/update activity reflected in the document metadata; the policy's last review date is recorded as 11/01/2023 in the brief and the policy text includes statements that it was developed and approved based on current standards and that coverage is subject to plan and regulatory requirements.