RetiredCapital BluecrossPolicy MP 2.086

Retinal Telescreening for Diabetic Retinopathy

This policy governs the medical necessity and coverage stance for retinal telescreening (digital retinal imaging with human or FDA-cleared AI interpretation) as a screening technique for detection of diabetic retinopathy for Capital Blue Cross products, with product/benefit variations noted.

Policy Summary

PayerCapital Bluecross

PolicyRetinal Telescreening for Diabetic Retinopathy

Policy CodePolicy MP 2.086

Change TypeRetired (policy lifecycle) and prior material revisions noted

Effective DateRETIRED 1/1/2026

Next Review Date

Key ActionVerify member benefits and product-specific prior authorization rules with Capital Blue Cross before billing codes 92227–92229.

SourceLink

POLICY UPDATE CHANGES

Policy retired.

Policy narrowed to focus on Retinal Telescreening; criteria around intraocular and fundus photography removed and code 92250 removed.

Changed automated image interpretation from investigational to medically necessary and moved codes 92228 and 92229 from investigational to medically necessary.

Added statement that Digital retinal imaging with automated image interpretation is considered investigational for the detection of diabetic retinopathy.

ICD-10 codes E10.A0-E10.A2 added effective 10/1/2024.

Consensus review with no change to policy statement; coding reviewed.

RetiredStatus

3Covered CPT codes

Coverage Criteria

Medical necessity criteria for retinal telescreening

Covered when ALL of the following are met

General coverage: Retinal telescreening with digital imaging and manual grading of images may be considered medically necessary as a screening technique for the detection of diabetic retinopathy.

Automated AI interpretation: Digital retinal imaging with image interpretation by U.S. Food and Drug Administration–approved artificial intelligence software (e.g., IDx-DR, EyeArt) may be considered medically necessary for screening for diabetic retinopathy.

Intended use: Use is limited to screening in individuals without a known diagnosis of diabetic retinopathy; retinal telescreening is considered investigational for monitoring or management of individuals already diagnosed with diabetic retinopathy or for other non‑screening indications.

Retinal telescreening is intended specifically as a screening technique to detect diabetic retinopathy in individuals without a known diagnosis of the disease. It is not intended for replacing in-person exams for diagnostic evaluation, treatment decisions, or longitudinal monitoring of patients with established diabetic retinopathy. Use of retinal telescreening for monitoring, management, or other non‑screening indications is outside the scope of the policy and is considered investigational.

Policy updates on 08/10/2022 narrowed the scope to focus solely on Retinal Telescreening: criteria related to intraocular and fundus photography were removed and CPT code 92250 was removed from the policy.

Retinal telescreening is considered investigational for indications other than screening, including the monitoring and management of individuals already diagnosed with diabetic retinopathy, because there is insufficient evidence to demonstrate improved health outcomes for these non‑screening uses.

The policy history notes that digital retinal imaging with automated image interpretation was initially listed as investigational (09/30/2020) but was changed to medically necessary on 07/13/2021, with corresponding coding adjustments moving CPT codes 92228 and 92229 from investigational to medically necessary.

Coding

Covered when medically necessaryCPTCovered

92227	Remote imaging for detection of retinal disease (per document grouping)
92228
92229

Associated diagnosis codes (examples listed)ICD-10

E08.00	Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.10	Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11	Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21	Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22	Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29	Diabetes mellitus due to underlying condition with other diabetic kidney complication

Covered CPT CodesCPTCovered

92227	Remote imaging for detection of retinopathy (screening) — as listed
92228	Remote imaging for detection of retinopathy (interpretation/reporting) — as listed
92229	Remote imaging for detection of retinopathy (remote image processing) — as listed

Applicable ICD-10 Codes (diabetes mellitus and complications)ICD-10

E08.00	Diabetes mellitus due to underlying condition with hyperosmolarity without NKHHC
E08.10	Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11	Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21	Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22	Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29	Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.36	Diabetes mellitus due to underlying condition with diabetic cataract
E08.37X1	Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye
E08.37X2	Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye
E08.37X3	Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral

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Policy retirement

Policy retirement date2025-07-28

Policy effective status after retirementRETIRED 1/1/2026

Policy identifierMP 2.086

Provider Actions / Billing Notes

Prior Authorization

Product / Plan Verification and Prior Authorization

This policy applies only to certain programs and products administered by Capital Blue Cross. Verify member benefits and eligibility prior to providing services. Federal Employee Program (FEP) members should be referred to the FEP Medical Policy Manual: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies

Policy applies only to certain Capital Blue Cross products and programs; verify member benefit plan language before delivering services
FEP members: follow FEP Medical Policy Manual rather than this policy

Prior Authorization

Prior Authorization / Coverage Coding

Prior authorization or coverage determination may be required depending on the member's benefit plan. The codes below are listed in the policy as covered when medically necessary, but actual coverage is determined by the member's benefits.

Background

Diabetic retinopathy is a progressive microvascular complication of diabetes and a leading cause of blindness in working‑age adults. Early identification through screening allows timely interventions (for example, improved glycemic and blood pressure control or ophthalmologic treatments) that reduce the risk of severe vision loss. Retinal telescreening — the acquisition of digital fundus images (mydriatic or nonmydriatic) with remote grading by trained readers or analysis by FDA‑cleared automated systems — is an alternative screening approach intended to increase detection and access to screening for individuals with diabetes.

Definitions

Retinal telescreening — acquisition and remote interpretation (mydriatic/nonmydriatic)

Definition — retinal telescreeningAcquisition of digital fundus images (mydriatic or nonmydriatic) transmitted for remote interpretation by trained readers; images may be acquired in primary care and evaluated remotely.

Image acquisition methodsDigital fundus photography can be performed with pupil dilation (mydriatic) or without dilation (nonmydriatic).

Transmission and interpretationCaptured digital images may be transmitted via the Internet to a remote center for interpretation, storage, and comparison by trained readers.

FDA-cleared automated analysis systems — examples and role

Examples of FDA-cleared automated analysis systemsIDx-DR (de novo clearance DEN180001, 2018) and EyeArt (510(k) K200667, 2020).