Electroretinography
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Defines medical necessity, limitations, and guideline-aligned uses of electroretinography (full-field, pattern, and multifocal ERG) for diagnostic evaluation of retinal and retinocortical dysfunction for AmeriHealth Caritas members.
Multifocal electroretinography is specified as the method to detect chloroquine and hydroxychloroquine toxicity.
Uses considered investigational/not medically necessary are listed explicitly (e.g., glaucoma, age-related macular degeneration, psychiatric disorders, Parkinson's disease, ALS, Fabry disease).
Coverage Criteria for Electroretinography
Medically necessary uses
Covered when the test is used as an adjunct to clinical assessment and imaging to localize or characterize retinal/retinocortical dysfunction in the following contexts:
Testing should be performed as an adjunct to standard clinical assessment, subjective tests of visual function, and retinal imaging and according to ISCEV/ professional standards for electrodes, stimuli, recording, and reporting.
Investigational / Not medically necessary
Not medically necessary / investigational when used for the following purposes:
Evidence is insufficient to support routine use for these indications; variability in methods and lack of validated reference ranges limit clinical utility.
All other uses of electroretinography not explicitly listed as medically necessary in this policy are considered investigational/not medically necessary. Claims for ERG performed for indications outside the covered list may be denied as not medically necessary.
Examples of uses considered investigational/not medically necessary include, but are not limited to: routine evaluation, early detection, or monitoring disease progression in suspected glaucoma, age-related macular degeneration, psychiatric disorders, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and Fabry disease. The evidence is insufficient to support routine clinical use of ERG for these emerging indications.
Related Procedure and Billing Codes
Provider Actions, Billing, and Documentation
Billing codes commonly submitted — confirm PA per plan
Prior authorization may be required per plan rules for ERG services billed with CPT codes 92273 (full-field ERG), 92274 (multifocal ERG), and 0509T (pattern ERG); providers should follow plan-specific prior authorization procedures when submitting these codes.
Alternative covered electrophysiologic services
Electro-oculography and visual evoked potential are listed as alternative covered diagnostic electrophysiologic services and may be considered as alternatives or complements to ERG when clinically appropriate.
- Electro-oculography
- Visual evoked potential
Required clinical context and ISCEV testing standards
Document that ERG is being used as an adjunct to standard clinical assessment, subjective visual function tests, and retinal imaging, and that testing follows ISCEV standards for electrodes, stimuli, recording, and reporting.
- Clinical indication and how ERG complements clinical exam and imaging
- Type of ERG ordered (ffERG, PERG, mfERG) and rationale (e.g., mfERG for hydroxychloroquine toxicity)
- Confirmation that testing will follow ISCEV standards for electrodes, stimuli, recording, patient preparation, analysis, and reporting
Denial risk when used for investigational/unproven indications
Claims for electroretinography used for investigational or not clinically proven indications risk denial; examples include use for suspected glaucoma, age-related macular degeneration, psychiatric disorders, Parkinson's disease, amyotrophic lateral sclerosis, and Fabry disease.
- Suspected glaucoma
- Age-related macular degeneration
- Psychiatric disorders
- Parkinson's disease
- Amyotrophic lateral sclerosis (ALS)
- Fabry disease
Background on Electroretinography
Electroretinography (ERG) objectively records the retina’s light-induced electrical responses and provides a noninvasive means to localize and characterize dysfunction in the retina and retinocortical pathway. Different ERG modalities serve distinct clinical roles: full-field ERG (ffERG) measures global retinal (rod and cone) function using Ganzfeld stimulation, pattern ERG (PERG) assesses central/macular ganglion cell function and helps differentiate macular versus optic nerve dysfunction, and multifocal ERG (mfERG) produces a topographic map of local macular activity to detect and localize discrete areas of damage. Testing and interpretation are performed according to recognized standards (for example, ISCEV) and ERG is intended to be used as an adjunct to clinical assessment and retinal imaging rather than as a standalone screening tool.
Definitions of ERG Modalities
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