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    v1.0.31
    OpenPayerPolicy UpdatesOphthalmology/OptometryAmeriHealth VIP Care ERG Coverage | OpenPayer
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    CurrentAmeriHealth Caritas VIP CarePolicy CCP.1523

    Electroretinography

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    This policy governs coverage of electroretinography used to localize and characterize retinocortical pathway dysfunction. It applies to providers requesting electroretinography for AmeriHealth Caritas VIP Care members, subject to medical-necessity criteria, plan benefits, and applicable laws and regulations.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyElectroretinography
    Policy CodePolicy CCP.1523
    Change TypeNo material change
    Effective DateJuly 1, 2026
    Last ReviewMay 1, 2026
    Next Review DateSeptember 1, 2027
    Key ActionDocument the clinical indication, relevant ophthalmic findings or unexplained visual impairment, and how electroretinography will supplement standard assessment, visual-function testing, and retinal imaging.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Electroretinography types described
    2Medically necessary use categories

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    6Not medically necessary indication groups
    2Alternative covered services
    3Commonly submitted codes

    Medical Necessity and Coverage Criteria

    Medically necessary electroretinography

    Electroretinography may be medically necessary when all of the following requirements are met:

    Covered use

    • Adjunctive testing: Electroretinography is performed as an adjunct to standard clinical assessment, subjective tests of visual function, and retinal imaging methods.

      The adjunctive testing requirement applies to the covered indications below.

    • ONE of the following medically necessary indications

      • Retinal function or lesion localization: The test is used to detect loss of retinal function or distinguish retinal from optic nerve lesions in hereditary eye disease, retinal vascular disease such as diabetic retinopathy, autoimmune retinopathy, congenital or acquired childhood nystagmus, or unexplained vision loss in children.

        The listed conditions are not all-inclusive.

      • Medication toxicity detection

        • Required modality: Multifocal electroretinography is used.

    Uses of electroretinography other than the clinically proven medically necessary indications described in this policy are considered investigational or not clinically proven and are therefore not medically necessary.

    Electroretinography is not medically necessary for the diagnosis, early detection, or monitoring of disease progression in members with suspected glaucoma, age-related macular degeneration, psychiatric disorders, Parkinson's disease, amyotrophic lateral sclerosis, or Fabry disease.

    Related Codes

    Related codesCPT
    92273Electroretinography (ERG), with interpretation and report; full field (i.e., ffERG, flash ERG, Ganzfeld ERG).
    92274Electroretinography (ERG), with interpretation and report; multifocal (mfERG).
    0509TElectroretinography (ERG) with interpretation and report, pattern (PERG)

    Documentation and Billing Guidance

    Documentation Required

    Document Clinical Rationale and Findings

    Document the clinical indication and relevant ophthalmic findings supporting electroretinography as an adjunct to standard clinical assessment, subjective tests of visual function, and retinal imaging. The electroretogram provides functional information that can help localize retinocortical pathway dysfunction when examination or structural imaging is normal, or when findings do not correlate with the nature or severity of visual impairment.

    • Loss of retinal function or differentiation of retinal from optic nerve lesions, including hereditary eye diseases, retinal vascular disease (such as diabetic retinopathy), autoimmune retinopathy, congenital or acquired childhood nystagmus, and unexplained vision loss in children.
    • Detection of chloroquine or hydroxychloroquine toxicity requires multifocal electroretinography only.
    • The choice of electroretinogram and order of testing should be individualized according to the clinical context.

    Clinical Background

    Electroretinography is a noninvasive electrophysiologic test that measures light-induced electrical activity in the retina. It can help localize and characterize retinocortical pathway dysfunction and complement routine ophthalmic examination, subjective visual-function testing, and retinal imaging. Full-field, pattern, and multifocal testing assess different aspects of retinal function and may identify electrophysiologic abnormalities before structural changes are evident on retinal imaging.

    Electroretinography Terms

    Electroretinogram
    PurposeMeasures light-induced electrical activity in the retina, including responses from rods and cones.
    Electrode typesUses a contact-lens electrode placed on the eye or conjunctiva, or skin electrodes attached to the lower eyelids.
    Recording methodRecords retinal responses to a series of lights using noninvasive electrodiagnostic testing.
    Full-field electroretinogram
    Stimulus and responseRecords the global or total electrical response of the retina at the corneal surface to a full-field (Ganzfeld) light stimulus.
    Functional distinctionsDistinguishes generalized outer and inner retinal dysfunction and predominantly rod or cone system dysfunction.
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyElectroretinography
    Policy CodePolicy CCP.1523
    Change TypeNo material change
    Effective DateJuly 1, 2026
    Last ReviewMay 1, 2026
    Next Review DateSeptember 1, 2027
    Key ActionDocument the clinical indication, relevant ophthalmic findings or unexplained visual impairment, and how electroretinography will supplement standard assessment, visual-function testing, and retinal imaging.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaRelated CodesDocumentation and Billing GuidanceClinical BackgroundElectroretinography Terms
    Billing Rule

    Use Current Coding Manuals

    The codes listed below are the most commonly submitted codes for services subject to this policy and are not exhaustive. Providers are expected to consult the appropriate coding manuals and bill accordingly.

    • 92273 — Electroretinography (ERG), with interpretation and report; full field (ffERG, flash ERG, or Ganzfeld ERG).
    • 92274 — Electroretinography (ERG), with interpretation and report; multifocal (mfERG).
    • 0509T — Electroretinography (ERG) with interpretation and report, pattern (PERG).
    Denial Risk

    Investigational Uses Are Not Covered

    All other uses of electroretinography are investigational, not clinically proven, and not medically necessary. Claims may be denied when electroretinography is used for diagnosis, early detection, or monitoring disease progression for the conditions below.

    • Suspected glaucoma
    • Age-related macular degeneration
    • Psychiatric disorders
    • Parkinson's disease
    • Amyotrophic lateral sclerosis
    • Fabry disease
    Clinical useHelps differentiate among various retinal diseases.
    Pattern electroretinogram
    PurposeMeasures central retinal function, with the response derived largely from macular retinal ganglion cells.
    StimulusUses a pattern-reversing black-and-white checkerboard or striped stimulus.
    Differentiating roleHelps differentiate macular disease from optic-nerve dysfunction.
    Multifocal electroretinogram
    Test typeA specialized type of pattern electroretinogram.
    LocalizationSimultaneously detects and localizes distinct areas of outer retinal damage in the macula, paramacular regions, and discrete peripheral areas.
    Topographic informationProvides a topographical map of retinal activity distribution, reflecting the integrity of central retinal (macula) function.
    Clinical correlationHelps correlate electrophysiologic findings with visual field testing.