CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Retinal telescreening (digital retinal imaging) for detection and monitoring of diabetic retinopathy — coverage criteria

Policy governing use and coverage of retinal telescreening (digital retinal imaging with manual or automated interpretation) for detection and monitoring of diabetic retinopathy for BCBSRI members, with distinctions between BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRetinal telescreening (digital retinal imaging) for detection and monitoring of diabetic retinopathy — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit remote retinal imaging claims only when filed by an optometrist or ophthalmologist and verify member-specific benefits before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare vs CommercialCoverage stance split

92227/92228Covered codes (Medicare)

92228 NMICommercial restriction

Multiple studiesEvidence cited

Multiple

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AI/automated references

Coverage Criteria

BlueCHiP for Medicare — Screening and monitoring

Covered when provided by an optometrist or ophthalmologist:

BlueCHiP for Medicare coverage: Retinal telescreening with digital imaging and manual grading performed by an optometrist or ophthalmologist may be considered medically necessary as a screening technique for detection of diabetic retinopathy or for monitoring and management of disease in individuals diagnosed with diabetic retinopathy.

Follow CMS guidelines; BlueCHiP for Medicare policies may differ from Commercial products.

Commercial — Screening only

Covered or not covered depending on indication:

Commercial coverage: Retinal telescreening with digital imaging and manual grading performed by an optometrist or ophthalmologist may be considered medically necessary as a screening technique for detection of diabetic retinopathy.

Commercial not medically necessary: Retinal telescreening is considered not medically necessary for all other indications, including the monitoring and management of disease in individuals diagnosed with diabetic retinopathy, as the evidence is insufficient to determine the effects of the technology on health outcomes.

Provision of fundus photography as a screening test must be performed by an ophthalmologist or optometrist. Fundus photography provided by other provider types is contrary to requirements codified in 42 CFR 410.32 and is not covered or reimbursable when used to facilitate referral to a specialist.

Services that are determined to be not medically necessary or that are non‑covered benefits are excluded from coverage. Providers may not charge the member for such services unless the member was informed and expressly agreed in advance to self‑pay; applicable provisions in the provider participation agreement also apply.

For Commercial products, retinal telescreening with digital imaging and manual grading performed by an optometrist or ophthalmologist is considered medically necessary only as a screening technique for detection of diabetic retinopathy. Retinal telescreening is not medically necessary for other indications, including the monitoring and management of diagnosed diabetic retinopathy; specifically, CPT 92228 (remote imaging for monitoring and management of active retinal disease) is listed as not medically necessary for Commercial products.

Providers may still perform services that the plan determines to be not medically necessary, but those services remain non‑covered unless the member has been notified and agreed in advance to accept financial responsibility. Verify member benefits and follow participation agreement requirements before billing the member.

Coding and Billing

BlueCHiP for Medicare covered codes when filed by optometrist or ophthalmologistCPTCovered

92228	Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral
92227	Remote imaging for detection of retinal disease (eg, retinopathy in patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral

Commercial coding stanceCPT

92227	Remote imaging for detection of retinal disease (eg, retinopathy in patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral
92228	Remote imaging for monitoring and management of active retinal disease (e:g, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral

Provider Actions and Filing Guidance

Prior Authorization

Prior authorization / coverage advisory

Prior authorization is not required for the services described in this policy. Check member-specific benefits and participation agreements for any exceptions.

Prior authorization: Not applicable — verify member benefits for plan-specific requirements

Denial Risk

Commercial denial for monitoring code

For Commercial products, CPT 92228 (remote imaging for monitoring and management of active retinal disease) is considered not medically necessary and should be denied when billed for monitoring purposes.

CPT 92228 — Not medically necessary for Commercial products

Denial Risk

Background

Diabetic retinopathy is a leading cause of vision loss in adults and progresses from early nonproliferative stages to sight‑threatening diabetic macular edema and proliferative retinopathy. Early disease is often asymptomatic, so regular screening is important because timely interventions (glycemic and blood pressure control, laser photocoagulation, and intravitreal therapies) can reduce the risk of vision loss. Digital fundus photography and telescreening increase access to screening and have demonstrated high concordance with conventional dilated fundus examination.

Definitions

Retinal telescreening / digital retinal imaging definition and process

DefinitionUse of digital fundus cameras to acquire standard-field color and/or monochromatic retinal images at a remote site for transmission, interpretation by trained readers, storage, and subsequent comparison.

Typical processImages are captured at the originating (remote) site (can be mydriatic or nonmydriatic), transmitted to trained readers or retinal specialists for interpretation, and stored for follow-up comparison.

Setting and personnelCan be performed in primary care or eye-care settings; interpretation and reporting must be performed by qualified readers — covered when performed by an optometrist or ophthalmologist per policy.

Clinical purposeUsed as an alternative to conventional dilated fundus examination for screening individuals with diabetes and for comparison over time to detect progression.

CPT 92227 definition — remote imaging for detection with analysis/report

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRetinal telescreening (digital retinal imaging) for detection and monitoring of diabetic retinopathy — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit remote retinal imaging claims only when filed by an optometrist or ophthalmologist and verify member-specific benefits before billing.

SourceLink

On This Page

Financial and denial risk notice

Services that are non-covered or determined not medically necessary may be denied. Providers may not bill members for non-covered services unless the member has been informed and has agreed in advance to accept financial responsibility. Refer to your participation agreement for applicable billing and collection rules.

Non-covered or not medically necessary services may result in claim denial and billing restrictions
Providers must obtain member agreement before billing member for non-covered services

Billing Rule

Filing requirements

Claims for fundus photography and related services should be submitted by an optometrist or ophthalmologist. Do not file CPT 92250 when the service is remote imaging without appropriate physician review. Follow coding guidance when submitting claims.

File fundus photography services only when billed by an optometrist or ophthalmologist
Do not file 92250 incorrectly for remote imaging without appropriate documentation/physician review

Documentation Required

Member eligibility and benefit documentation

Verify member eligibility and benefit details before providing services. For member-specific benefits, coverage determinations, and participation agreement implications, contact the provider call center. Member subscriber agreements and employer contracts govern coverage and supersede this policy.

Contact the provider call center for member-specific benefits and eligibility
Member certificate/subscriber agreement and employer agreements govern coverage

DescriptionRemote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral.

Coverage noteCovered when filed by an optometrist or ophthalmologist (BlueCHiP for Medicare and Commercial when filed by these providers).

CPT 92228 definition — remote imaging for monitoring and management with physician review/report

CPT code92228

DescriptionRemote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral.

Commercial coverage stanceFor Commercial products, 92228 is listed as not medically necessary and may be denied; for BlueCHiP for Medicare, 92228 is covered when filed by an optometrist or ophthalmologist.

Automated diabetic retinopathy image assessment — AI/software detection systems

DefinitionSoftware and deep-learning systems that analyze retinal images to detect referable diabetic retinopathy or other retinal pathology (automated diabetic retinopathy image assessment).

Evidence baseMultiple studies and systematic reviews have evaluated diagnostic accuracy and cost-effectiveness of automated DR image assessment systems (see referenced studies).

Role in careThese systems have been evaluated as potential replacements for or adjuncts to manual grading, with studies assessing whether they can replace steps of manual grading and their cost-effectiveness.