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CurrentAmbetter NevadaPolicy CP.VP.29

Fundus Photography (Clinical Policy)

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Medical necessity guidelines for fundus photography (retinal imaging) including indications and non-covered situations; applies to members of Centene/Envolve Vision plans (Ambetter Nevada).

Policy Summary

PayerAmbetter Nevada

PolicyFundus Photography (Clinical Policy)

Policy CodePolicy CP.VP.29

Change TypeNo material changes noted

Effective Date

Last ReviewNov 20, 2023

Next Review Date

Key ActionDocument the applicable ICD-10 diagnosis code(s) that justify the need for fundus photography when submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Primary CPT code referenced

11Medically necessary indications

3Not medically necessary scenarios

OphthalmologySpecialty

11/2023Last review

Coverage Criteria for Fundus Photography

inv-01: Medically Necessary Indications

Covered when ANY ONE of the following indications is present

Indications for medical necessity: A. Histoplasmosis

From policy I.A.

Indications for medical necessity: B. Choroidal neoplasms

From policy I.B.

Indications for medical necessity: C. Glaucoma

From policy I.C.

Indications for medical necessity: D. Optic nerve pathology

Policy Summary

PayerAmbetter Nevada

PolicyFundus Photography (Clinical Policy)

Policy CodePolicy CP.VP.29

Change TypeNo material changes noted

Effective Date

Last ReviewNov 20, 2023

Next Review Date

Key ActionDocument the applicable ICD-10 diagnosis code(s) that justify the need for fundus photography when submitting claims.

SourceLink

On This Page

Indications for medical necessity: E. Diabetic retinopathy

From policy I.E.

Indications for medical necessity: F. Hypertensive retinopathy

From policy I.F.

Indications for medical necessity: G. Vascular occlusion

From policy I.G.

Indications for medical necessity: H. Retinal neovascularization

From policy I.H.

Indications for medical necessity: I. Macular pathology

From policy I.I.

Indications for medical necessity: J. Retinal tear, thinning, schisis or detachment

From policy I.J.

Indications for medical necessity: K. Hereditary retinal dystrophies

From policy I.K.

Indications for medical necessity: L. Other visible retinal disorders requiring detailed imaging for adequate documentation

From policy I.L.

inv-02: Not Medically Necessary

Not covered when ANY of the following apply

Not medically necessary situations: A. Routine replacement of standard ophthalmoscopy with fundus photography to document the appearance of healthy retinal anatomy

From policy II.A

Not medically necessary situations: B. Duplicative documentation of retinal pathology with fundus photography in conjunction with extended ophthalmoscopy, fluorescein angiography, etc., unless the additional diagnostic procedures provide new information to assist in clinical decision-making

From policy II.B

Not medically necessary situations: C. Repeated performance in the presence of controlled and/or stable disease

From policy II.C

Fundus photography produces photographic or digital images of the vitreous, retina, choroid, and optic nerve and images become part of the patient’s permanent record. Fundus photography shall not replace a thorough dilated fundus exam and should be employed only when photographic documentation is necessary to ongoing management of the specific ocular disease process. It is not intended as a routine substitute for standard ophthalmoscopy and may be used as a screening tool only in the narrow circumstance of teleretinal diabetic retinopathy evaluation when a patient is non‑compliant with diabetic eye examinations (preferred that the patient establish care with an eye care provider for comprehensive evaluation).

This section of the policy lists extensive ICD‑10 diagnosis codes that support performance of fundus photography for specific posterior segment, optic nerve, vascular, inflammatory, diabetic and other retinal conditions. The presence of a listed diagnosis is required to demonstrate the clinical indication for fundus photography; however, the absence of a specific diagnosis from the enumerated lists in the document does not imply coverage.

The policy history documents periodic updates to coding and indications. During prior annual reviews the policy was amended to add conditions under which fundus photography is considered not medically indicated and to update the ICD‑10 diagnosis lists (for example, additions to include penetrating orbital wounds, parasitic retinal cysts, and later updates for sickle‑cell retinopathy). These historical changes should be considered when assessing claims and clinical documentation.

Fundus photography is considered not medically necessary for: A) routine replacement of standard ophthalmoscopy to document healthy retinal appearance; B) duplicative documentation of pathology when other diagnostic methods (extended ophthalmoscopy, fluorescein angiography, etc.) already document the findings unless the photographic images provide new information that will alter management; and C) repeated performance for controlled or stable disease. Photographic studies should only be performed when they add necessary information to ongoing care.

Providers must document an appropriate ICD‑10 diagnosis code that supports medical necessity when billing for fundus photography; claims lacking diagnosis codes demonstrating the clinical indication may be denied. The policy contains an extensive, enumerated list of supporting ICD‑10 codes for posterior segment, retinal, optic nerve, diabetic and related conditions — use the listed codes when they reflect the clinical reason for the images. Where diagnosis codes are not listed or where prior reviews added specific conditions as not medically indicated, lack of a listed indication increases the risk of denial.

Note: the policy record shows that certain conditions have been explicitly added in prior reviews as not medically indicated. The full text of those specific exclusions may not be present in this excerpt; reviewers and billing staff should consult the complete, up‑to‑date policy and change history when evaluating coverage for borderline or uncommon diagnoses.

Denial Risk

Denial risk and documentation: avoid routine replacement or duplicative fundus photography

Fundus photography is not medically necessary when used to routinely replace a standard dilated ophthalmoscopic exam, when it merely duplicates documentation already obtained by other diagnostic procedures without providing new information to guide care, or when repeated studies are performed for controlled or stable disease; images are part of the permanent record and should be performed only when photographic documentation is necessary to ongoing management and not as a substitute for a thorough dilated fundus exam.

Do not bill fundus photography to replace routine ophthalmoscopy of healthy retinal anatomy (denial risk).
Avoid duplicative fundus photography when extended ophthalmoscopy, fluorescein angiography, or other diagnostics already document the pathology unless new information is obtained; otherwise claims may be denied.
Reimbursement risk if fundus photography is repeated for controlled or stable disease without clinical justification.
Ensure images and the clinical rationale are retained in the patient’s permanent medical record; fundus photography generally is obtained through dilated pupils unless clinically unnecessary or contraindicated.

CPT and ICD-10 Coding

Covered CPT CodesCPTCovered

92250

Fundus photography with interpretation and report

Example ICD-10 Codes Supporting Coverage (partial list)ICD-10

A18.53	Tuberculous chorioretinitis
A51.43	Secondary syphilitic oculopathy
A52.15	Late syphilitic neuropathy
B20	Human immunodeficiency virus [HIV] disease
B25.8	Other cytomegaloviral diseases
B39.4	Histoplasmosis capsulati, unspecified
B39.5	Histoplasmosis duboisii
B58.01	Toxoplasma chorioretinitis
C69.21	Malignant neoplasm of right retina
C69.22	Malignant neoplasm of left retina

Covered ICD-10 Diagnosis Codes (section)ICD-10Covered

E09.3553	Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E09.3591	Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E09.3592	Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E09.3593	Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E09.37X1	Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E09.37X2	Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E09.37X3	Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E10.3211	Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E10.3212	Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213	Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

1–10 of 55

1/6

Diagnosis codes (segment)ICD-10

H34.213	Partial retinal artery occlusion, bilateral
H34.231	Retinal artery branch occlusion, right eye
H34.232	Retinal artery branch occlusion, left eye
H34.233	Retinal artery branch occlusion, bilateral
H34.8110	Central retinal vein occlusion, right eye, with macular edema
H34.8111	Central retinal vein occlusion, right eye, with retinal neovascularization
H34.8112	Central retinal vein occlusion, right eye, stable
H34.8120	Central retinal vein occlusion, left eye, with macular edema
H34.8121	Central retinal vein occlusion, left eye with retinal neovascularization
H34.8122	Central retinal vein occlusion, left eye, stable

1–10 of 21

1/3

Diagnosis codes (segment)ICD-10

H34.8322	Tributary (branch) retinal vein occlusion, left eye, stable
H34.8330	Tributary (branch) retinal vein occlusion, bilateral, with macular edema
H34.8331	Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization
H34.8332	Tributary (branch) retinal vein occlusion, bilateral, stable
H35.011	Changes in retinal vascular appearance, right eye
H35.012	Changes in retinal vascular appearance, left eye
H35.013	Changes in retinal vascular appearance, bilateral
H35.021	Exudative retinopathy, right eye
H35.022	Exudative retinopathy, left eye
H35.023	Exudative retinopathy, bilateral

1–10 of 19

1/2

Diagnosis codes (segment)ICD-10

H35.061	Retinal vasculitis, right eye
H35.062	Retinal vasculitis, left eye
H35.063	Retinal vasculitis, bilateral
H35.071	Retinal telangiectasis, right eye
H35.072	Retinal telangiectasis, left eye
H35.073	Retinal telangiectasis, bilateral
H35.111	Retinopathy of prematurity, stage 0, right eye
H35.112	Retinopathy of prematurity, stage 0, left eye
H35.113	Retinopathy of prematurity, stage 0, bilateral
H35.121	Retinopathy of prematurity, stage 1, right eye

1–10 of 22

1/3

Diagnosis codes (continued segment)ICD-10

H35.21	Other non-diabetic proliferative retinopathy, right eye
H35.22	Other non-diabetic proliferative retinopathy, left eye
H35.23	Other non-diabetic proliferative retinopathy, bilateral
H35.3111	Nonexudative age-related macular degeneration, right eye, early dry stage
H35.3112	Nonexudative age-related macular degeneration, right eye, intermediate dry stage
H35.3113	Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement
H35.3114	Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement
H35.3121	Nonexudative age-related macular degeneration, left eye, early dry stage
H35.3122	Nonexudative age-related macular degeneration, left eye, intermediate dry stage
H35.3123	Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement

1–10 of 35

1/4

Listed ICD-10 Codes related to fundus photography indicationsICD-10

H44.653	Retained (old) magnetic foreign body in vitreous body, bilateral
H44.691	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, right eye
H44.692	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, left eye
H44.693	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, bilateral
H44.711	Retained (nonmagnetic) (old) foreign body in anterior chamber, right eye
H44.712	Retained (nonmagnetic) (old) foreign body in anterior chamber, left eye
H44.713	Retained (nonmagnetic) (old) foreign body in anterior chamber, bilateral
H44.721	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, right eye
H44.722	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, left eye
H44.723	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, bilateral

1–10 of 138

1/14

Policy approval history

Original approval12/2019

Template conversionConverted to new template 05/2020 (approval 06/2020)

Annual review - updates12/2020 (updated references)

Added NMN conditions & ICD-10 updates12/2021 (approval 01/2022)

Most recent updateUpdated diagnoses for sickle-cell retinopathy 11/2023 (approval 12/2023)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization / coding reference: CPT 92250

Use CPT code 92250 (Fundus photography with interpretation and report) when billing for fundus photography; medical necessity for the service is defined by the policy's listed indications and not‑medically‑necessary situations.

CPT 92250 = Fundus photography with interpretation and report

Prior Authorization

Prior authorization: ICD‑10 codes listed (PA requirements not specified)

The policy includes an extensive list of ICD‑10 diagnosis codes that support fundus photography; the policy chunks listing those codes do not specify prior authorization requirements.

Prior Authorization

Prior authorization not specified in excerpts

No prior authorization requirements for fundus photography are stated in the provided policy excerpts.

Prior Authorization

Prior authorization: verify medical necessity and follow payer/NCD/LCD/state rules

Verify medical necessity per the Health Plan's procedures and ensure applicability of this clinical policy; for Medicare/Medicaid members, applicable NCDs, LCDs, or state Medicaid provisions take precedence and should be reviewed prior to applying the policy criteria.

Follow Health Plan prior authorization procedures where applicable
Review applicable Medicare NCDs/LCDs or state Medicaid rules for members covered by those programs

Note

Use limitation: not a screening tool except select teleretinal diabetic evaluations

Fundus photography shall not be used as a screening tool except for teleretinal evaluation for diabetic retinopathy when a patient is non‑compliant with diabetic eye examinations; otherwise it should not replace a comprehensive dilated fundus exam.

Preferred that patient establish care with an eye care provider for comprehensive diabetic eye evaluation

Step Therapy

Step therapy: not specified

No step therapy requirements for fundus photography are stated in the provided policy excerpts.

Step Therapy

Step therapy: not specified (alternate)

No step therapy requirements are specified in the provided text.

Documentation Required

Records and imaging: include images in permanent record; typically dilated pupils

Fundus photographs and any images become part of the patient's permanent medical record; images are usually obtained through a dilated pupil unless unnecessary for image acquisition or clinically contraindicated.

Documentation Required

Document supporting diagnosis: record applicable ICD‑10 code(s)

Document the applicable ICD‑10 diagnosis code(s) that justify fundus photography when submitting claims and in the medical record; the policy provides numerous example and covered ICD‑10 codes to support medical necessity.

Include diagnosis codes that directly support the clinical indication for imaging

Documentation Required

ICD‑10 code listings: support documentation of medical necessity

The policy lists extensive ICD‑10 diagnosis codes that support performance and billing of fundus photography; use those codes to substantiate medical necessity in claims and documentation.

Documentation Required

Follow applicable Medicare/Medicaid rules for members

For Medicare and Medicaid members, ensure claims and prior authorizations comply with applicable NCDs, LCDs, or state Medicaid provisions, which take precedence over this clinical policy when conflicts exist.

Denial Risk

Denial risk: diagnosis coding required on claims

Claims for fundus photography may be denied if diagnosis codes demonstrating medical necessity are not submitted with the charges.

Include a diagnosis code from the policy’s supported list that reflects the clinical indication

Note

Authorization/denial triggers: none specified in code listing sections

The provided policy chunks list diagnosis codes only and do not specify explicit authorization or denial triggers.

Denial Risk

Denial risk: claims may be denied when diagnosis not listed or deemed not medically indicated

Claims lacking an indication within the policy's listed medically indicated diagnoses risk denial because the policy has identified certain conditions as not medically indicated in prior updates.

Note

Use limitation (duplicate): teleretinal screening exception only for non‑compliant diabetic patients

Fundus photography may not be used as a screening tool except for teleretinal diabetic retinopathy evaluations in non‑compliant patients; this is reiterated in the policy's use‑limitation language.

Background

Fundus photography uses a retinal camera to capture photographic or digital images of the vitreous, retina, choroid, and optic nerve; these images are typically taken through dilated pupils unless clinically unnecessary or contraindicated. The modality documents posterior segment anatomy and pathology to support clinical management and becomes part of the member’s permanent medical record.

Definitions and Terminology

Fundus photography — definition

ModalityUse of a retinal camera to photograph vitreous, retina, choroid, and optic nerve

Image typePhotographic or digital images

Record retentionImages become part of the patient's permanent record

Pupil dilationUsually obtained through a dilated pupil unless unnecessary or clinically contraindicated

Fundus autofluorescence — definition

PrincipleAutofluorescent signals arise from fluorophores (eg, lipofuscin) releasing signal while melanin and rhodopsin absorb excitation

Clinical meaningSpatial/background autofluorescence reflects distribution of photoreceptors and RPE cells

Hyper- vs hypo-autofluorescenceHyperautofluorescence often from lipofuscin accumulation; hypo-autofluorescence from decreased lipofuscin or blockage by anterior material

Diabetic retinopathy codes (E08–E13 series)

Code seriesE08–E13 (diabetes mellitus codes) with specific DR manifestations listed (eg, E09.3553, E10.3211, E11.3211)

Included conditionsCodes cover mild/moderate/severe nonproliferative, proliferative DR, diabetic macular edema, resolved DME following treatment

Drug/chemical inducedIncludes drug/chemical induced diabetes mellitus codes with DR subtypes (eg, E09.3591, E09.37X1)

Retinal vascular occlusion and related vitreoretinal codes

Primary code groupsH34.* (retinal artery/vein occlusions) and H33.* (retinal detachments/tears) are listed

ExamplesH34.8110 (CRVO right with macular edema), H34.231 (retinal artery branch occlusion), H33.011 (retinal detachment with single break)

Related vitreoretinal conditionsVenous engorgement, tributary/branch RVO, retinal neovascularization (H35.*) are included

Fundus photography indication codes

ScopeICD-10 codes for retinal, vitreous, choroidal, optic nerve, and glaucoma conditions may justify fundus photography (see H30.*, H31.*, H33.*, H34.*, H35.*, H40.*)

Representative categoriesInflammatory/chorioretinal disease, macular disorders, retinopathy of prematurity, proliferative/nonproliferative retinopathies

Billing implicationProviders should submit applicable ICD-10 diagnosis codes from these groups to demonstrate medical necessity

Policy Revision History

2019-12original_approval

Policy originally approved (Original approval date 12/2019).

2020-05template_conversion

Converted to new template (Converted to new template, Date = 05/2020).

2020-12annual_review

Annual review with updated references (Annual Review; Updated references, Date = 12/2020).

2021-12annual_review_update

Annual review; added conditions under which fundus photography is not medically indicated and updated ICD-10 codes to include penetrating orbital wounds and parasitic retinal cysts (Date = 12/2021).

2022-01approval_date_update

Approval recorded for prior annual updates (Approval Date = 01/2022).

2022-11annual_review

Annual review conducted (Annual Review, Date = 11/2022).

2022-12approval_date_update

Approval recorded for 2022 annual review (Approval Date = 12/2022).

2023-11code_update

Updated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy (Date = 11/2023).

2023-12approval_date_updateLatest

Approval recorded for 2023 updates including sickle-cell retinopathy codes (Approval Date = 12/2023).