CurrentArizona Complete HealthPolicy OC.UM.CP.0029

Fundus Photography

Medical necessity guidelines for fundus photography (retinal imaging) including indications and supporting coding/diagnosis lists for providers and payers associated with Arizona Complete Health/Envolve Vision, Inc.

Policy Summary

PayerArizona Complete Health

PolicyFundus Photography

Policy CodePolicy OC.UM.CP.0029

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document fundus photographs only when photographic documentation is necessary to ongoing management; do not substitute imaging for a dilated fundus exam.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12+Medically necessary indications

20+Diagnosis codes listed

05/2020Last review

12/2019Original approval

Coverage Criteria

inv-01: Medically Necessary Indications

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Medically Necessary Indications: Histoplasmosis

From policy indication list.

Medically Necessary Indications: Choroidal neoplasms

From policy indication list.

Medically Necessary Indications: Glaucoma

From policy indication list.

Medically Necessary Indications: Optic nerve pathology

From policy indication list.

Medically Necessary Indications: Diabetic retinopathy

From policy indication list.

Medically Necessary Indications: Hypertensive retinopathy

From policy indication list.

Medically Necessary Indications: Vascular occlusion

From policy indication list.

Medically Necessary Indications: Retinal neovascularization

From policy indication list.

Medically Necessary Indications: Macular pathology

From policy indication list.

Medically Necessary Indications: Retinal tear, thinning, schisis or detachment

From policy indication list.

Medically Necessary Indications: Hereditary retinal dystrophies

From policy indication list.

Medically Necessary Indications: Other visible retinal disorders requiring detailed imaging for adequate documentation

From policy indication list.

inv-02: Supported Diagnoses (excerpt)

Diagnosis codes listed in this excerpt support clinical indications for fundus photography when associated with retinal disease. Examples from the document include but are not limited to:

Supported diagnoses - diabetic retinopathy variants: ICD-10-CM codes for diabetic retinopathy (type 1, type 2, drug-induced, other specified) across nonproliferative, proliferative, with/without macular edema and post-treatment/resolved macular edema states (examples shown in the excerpt: E09.*, E10.*, E11.*, E13.*).

See listed codes in chunks 18-20 for full enumerations.

Supported diagnoses - vascular and occlusive disease: ICD-10-CM codes for retinal artery and vein occlusions and related vascular findings (H34.x series and related H35 vascular appearance codes).

Retinal vascular occlusions and related codes are enumerated in the policy excerpt.

Supported diagnoses - retinal detachment and structural disorders: ICD-10-CM codes for retinal tear, detachment, schisis and other structural retinal changes (H33.x, H31.x series).

Retinal detachment and structural disorder codes appear in the document excerpt.

Supported diagnoses - inflammatory, infectious and chorioretinal disease: ICD-10-CM codes for focal and disseminated chorioretinal inflammation, posterior scleritis, infectious chorioretinitis (examples include H30.*, H15.*, A18.53, B39.*, B58.01).

Inflammatory and infectious retinal diagnoses are included in the excerpt lists.

Supported diagnoses - macular degeneration and macular pathology: ICD-10-CM codes for nonexudative and exudative age-related macular degeneration and other macular disorders (H35.31x–H35.32x and related H35.* codes).

Macular pathology codes are enumerated in the policy excerpt.

Supported diagnoses - neoplasm and hereditary retinal dystrophies: ICD-10-CM codes for benign and malignant choroidal/retinal neoplasms and hereditary retinal dystrophies (examples include C69.*, D31.*, H31.*).

Neoplasm and dystrophy codes are present in the listed diagnosis excerpt.

inv-03: Medical necessity guidance (document continuation)

Policy purpose and usage guidance

Policy purpose: This clinical policy provides guidance to determine medical necessity for fundus photography and is intended to assist in coverage decisions and benefit administration; it is not a contract or payment guarantee.

From policy statement of purpose and limitations.

Provider responsibilities: Providers should exercise professional medical judgment; follow applicable coverage documents, state/federal requirements, and consult NCDs/LCDs for Medicare members where applicable.

Guidance for provider use and applicability from policy continuation.

Administrative considerations: The Health Plan may adopt, amend, or withdraw this clinical policy; effective date is determined by the Health Plan and coverage is subject to plan-specific terms, exclusions and limitations.

Administrative and legal caveats from the policy; see referenced LCDs in References.

Provider Actions & Requirements

Billing Rule

Coding and claim submission guidance

Providers should reference the most current coding guidance prior to claim submission. CPT codes and descriptions are updated periodically; inclusion or exclusion of codes in this policy does not guarantee coverage. Codes referenced are for informational purposes only.

Reference current CPT manuals and professional coding resources before submitting claims
Inclusion/exclusion of codes in this policy is informational only and does not guarantee coverage

Prior Authorization

Prior authorization guidance

This clinical policy is used to assist in making coverage decisions and administering benefits; prior authorization requirements may be imposed by the Health Plan or specific contracts. Providers must follow the Health Plan's prior authorization procedures where required.

Policy provides medical necessity guidance but does not itself grant authorization
Check member-specific plan documents and Health Plan administrative policies for prior authorization requirements

Denial Risk

Inappropriate use / screening risk

Fundus photography shall not replace a comprehensive dilated fundus exam and is not appropriate as a general screening tool. An exception exists for teleretinal evaluation for diabetic retinopathy when a patient is non-compliant with in‑person diabetic eye examinations; however, establishing a relationship with an eye care provider and receiving a comprehensive diabetic eye evaluation is preferred.

Do not use fundus photography as a substitute for a thorough dilated fundus exam
Teleretinal screening may be allowed only when the patient is non-compliant with diabetic eye exams

Step Therapy

Step therapy

No specific step therapy requirements are provided in this policy excerpt.

If step therapy applies, follow applicable plan-level policies

Denial Risk

Denial triggers

Denial may occur if services are submitted without meeting plan criteria, without required prior authorization when applicable, or when fundus photography is used inappropriately as a screening substitute for a comprehensive exam.

Ensure documentation supports medical necessity per policy criteria
Verify prior authorization when required by the Health Plan

Note

Provider actions (not specified in this excerpt)

No additional provider actions were specified in this segment of the policy beyond those listed elsewhere in these Provider Actions and Requirements.

Documentation Required

Documentation requirements

Documentation: Fundus photographs become part of the patient's permanent medical record. Providers should document the clinical indication, findings, and how the images informed management. No explicit additional documentation requirements are stated in this segment.

Document clinical indication for fundus photography
Include images in the patient's permanent record and document their role in ongoing management

Note

Coverage / contract constraints

Coverage decisions are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and to state and federal requirements. This policy does not guarantee payment; providers remain responsible for confirming member benefits and applicable administrative policies.

Verify member eligibility and benefit limitations in the evidence of coverage, certificate of coverage, or contract
Comply with state and federal requirements and applicable Health Plan administrative policies

Definitions

Fundus photography

DefinitionUse of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve; resultant images (photographic or digital) become part of the patient's permanent record.

Typical techniqueImages are usually taken through a dilated pupil to enhance image quality unless unnecessary or clinically contraindicated.

RecordkeepingFundus photographs are incorporated into the patient’s permanent medical record and should be available for ongoing management and documentation.

Fundus autofluorescence

DefinitionImaging modality that records intrinsic autofluorescent patterns of the retina and retinal pigment epithelium driven primarily by fluorophores such as lipofuscin (and influenced by melanin, rhodopsin, retinal vessels, and lens), producing hyper- or hypo-autofluorescent signatures.

Hyperautofluorescence mechanismOften due to accumulation of lipofuscin or bisretinoids in RPE/photoreceptors (e.g., Stargardt disease, geographic atrophy) or window defects from rhodopsin loss.

Hypoautofluorescence mechanismMay reflect decreased lipofuscin (RPE atrophy, RPE tears) or blockage by material anterior to the RPE (hemorrhage, fibrosis, media opacities).

Diabetic retinopathy codes

Scope of codesMultiple ICD-10-CM codes for type 1, type 2, drug-induced, and other specified diabetes mellitus with classifications by severity (mild/moderate/severe), proliferative vs nonproliferative, presence/absence of macular edema, and laterality.

Examples (type 1)E10.3211, E10.3291, E10.3311, E10.3411, E10.3511 (various nonproliferative/proliferative retinopathy with/without macular edema, right eye).

Examples (type 2)E11.3521, E11.3551, E11.3591 (proliferative and stable proliferative diabetic retinopathy variants involving macular or tractional detachment).

Retinal artery/vein occlusion codes

ICD-10 seriesH34.x series describing retinal arterial and venous occlusions (transient, central, partial, branch) and central/branch retinal vein occlusion variants.

Examples - artery occlusionsH34.01, H34.02, H34.03, H34.11, H34.12, H34.13, H34.211–H34.233 (transient, central, partial, branch; laterality specified).

Examples - vein occlusionsH34.8110–H34.8132 and H34.8310–H34.8332 (central and branch retinal vein occlusion codes with macular edema, neovascularization, or stable status).

Age-related macular degeneration codes

ICD-10 rangeH35.31x–H35.32x codes describing nonexudative (dry) and exudative (wet) age-related macular degeneration stages and activity status.

Examples - nonexudative (dry)H35.3111–H35.3134 (right, left, bilateral; early to advanced atrophic stages).

Examples - exudative (wet)H35.3211–H35.3233 (right, left, bilateral; active or inactive choroidal neovascularization and scarring).

Fundus photography / posterior segment imaging

External referencesPolicy references LCDs (e.g., First Coast L33670; National Government Service L33567) and AAO Preferred Practice Patterns for posterior segment imaging and fundus photography.

Practice guidanceFundus photography/posterior segment imaging should be used consistent with LCDs and AAO Preferred Practice Pattern guidance for indications and technique.

Documentation noteImages become part of the patient's permanent record and should support ongoing management as described in AAO and LCD guidance.

OpenPayer

Fundus Photography

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions