Centene Fundus Photography Coverage Update

Indications (Initial/Any)

Fundus photography is medically necessary for ANY of the following indications:

Medically necessary indications: Histoplasmosis

From policy chunk 2

Medically necessary indications: Choroidal neoplasms

From policy chunk 2

Medically necessary indications: Glaucoma

From policy chunk 2

Medically necessary indications: Optic nerve pathology

From policy chunk 2

Medically necessary indications: Diabetic retinopathy

From policy chunk 2

Medically necessary indications: Hypertensive retinopathy

From policy chunk 2

Medically necessary indications: Vascular occlusion

From policy chunk 2

Medically necessary indications: Retinal neovascularization

From policy chunk 2

Medically necessary indications: Retinal tear, thinning, schisis or detachment

From policy chunk 2

Medically necessary indications: Macular pathology

From policy chunk 2

Medically necessary indications: Hereditary retinal dystrophies

From policy chunk 2

Medically necessary indications: Other visible retinal disorders requiring detailed imaging for adequate documentation

From policy chunk 2

Not Medically Necessary

Fundus photography is NOT medically necessary when performed for ANY of the following situations:

Not medically necessary scenarios: Routine replacement of standard ophthalmoscopy to document the appearance of a healthy retina

From policy chunk 2

Not medically necessary scenarios: Duplicative documentation of retinal pathology when performed in conjunction with extended ophthalmoscopy, fluorescein angiography, or similar procedures unless the additional procedure provides new information that affects clinical decision-making

From policy chunk 2

Not medically necessary scenarios: Repeated performance for controlled and/or stable disease

From policy chunk 2

Diagnosis codes supporting coverage

Covered when the member has one of the following ICD-10-CM diagnoses that align with the service provided

Supported ICD-10 codes: Any single listed ICD-10-CM code in the 'ICD-10-CM Diagnosis Codes that Support Coverage Criteria' section may be used to support coverage for related ophthalmic services, according to the policy's clinical criteria in other sections.

Code lists appear in chunks 18, 36-37, 54-62

Diagnosis support

Diagnosis codes that support coverage when paired with the policy's clinical criteria

Use of listed ICD-10-CM codes: When the clinical coverage criteria in other parts of the policy are met, the diagnoses listed in this section support coverage determinations.

See ICD-10-CM code listings in chunks 36 and 55

Medically Indicated Diagnoses

Fundus photography is considered medically indicated when associated with the following diagnoses (ICD-10-CM codes):

Diagnosis list: Presence of any listed ICD-10-CM diagnosis that supports coverage for fundus photographyN/A

Full code listings provided in chunks 54-62

Fundus photography uses a retinal camera to capture photographic or digital images of the posterior segment (vitreous, retina, choroid, and optic nerve) that become part of the patient’s permanent record. It should be used only when photographic documentation is necessary to ongoing management of a specific ocular disease and shall not replace a thorough dilated fundus examination. Pupil dilation is usually performed unless unnecessary for image acquisition or clinically contraindicated. (See policy indications for specific diagnoses that warrant imaging.)

In the portions of the document that list ICD-10-CM codes supporting coverage, no explicit exclusions or ‘‘not medically necessary’’ scenarios are stated; those sections are limited to code listings intended to substantiate the ocular diagnosis associated with the imaging request.

The diagnosis-code sections that follow this guidance similarly provide supporting ICD-10-CM codes only and do not themselves enumerate conditions or scenarios that are expressly excluded from coverage; clinical application and exclusion logic are defined elsewhere in the policy text.

Previous annual reviews of this policy explicitly added language identifying conditions under which fundus photography is not considered medically indicated. Those earlier updates are noted in the document history, though the specific prior-review exclusion wording is outside the current code-list extracts.

The policy specifies several scenarios where fundus photography is not medically necessary: routine replacement of standard ophthalmoscopy to document a healthy retina, duplicative documentation when performed alongside extended ophthalmoscopy or fluorescein angiography unless the additional imaging provides new information that affects clinical decision-making, and repeated performance for controlled or stable disease. Providers should ensure imaging is clinically justified and not merely duplicative or routine.

Within the ICD-10-CM code listings themselves, the document does not restate the ‘‘not medically necessary’’ conditions; those clinical determinations are contained in the policy narrative sections rather than in the code tables.

This segment of the policy (diagnosis code listings) does not enumerate conditions designated as not medically necessary; it functions as a reference list of diagnoses that can support coverage when the clinical criteria are met elsewhere in the policy.

The policy history records that prior reviews added explicit statements about conditions under which fundus photography is not considered medically indicated. The current extracted code-list portions therefore should be interpreted together with the main clinical criteria sections which contain the actionable NMN (not medically necessary) rules.

Coding

ICD-10 Diagnosis Codes that Support Coverage Criteria (selected diabetic retinopathy and related codes)ICD-10Covered

E10.3492	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3511	Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E10.3512	Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E10.3513	Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3521	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E10.3522	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E10.3523	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3531	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532	Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

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inv-17: Retinal vascular occlusion and central retinal vein occlusion codesICD-10Covered

H34.8110	Central retinal vein occlusion, right eye, with macular edema
H34.8112	Central retinal vein occlusion, right eye, stable
H34.8120	Central retinal vein occlusion, left eye, with macular edema
H34.8121	Central retinal vein occlusion, left eye, with retinal neovascularization
H34.8122	Central retinal vein occlusion, left eye, stable
H34.8130	Central retinal vein occlusion, bilateral, with macular edema
H34.8131	Central retinal vein occlusion, bilateral, with retinal neovascularization
H34.8132	Central retinal vein occlusion, bilateral, stable
H34.8310	Tributary (branch) retinal vein occlusion, right eye, with macular edema
H34.8311	Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization

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inv-18: Retinal findings, vasculitis, neovascularization, exudative retinopathyICD-10Covered

H35.011	Changes in retinal vascular appearance, right eye
H35.012	Changes in retinal vascular appearance, left eye
H35.013	Changes in retinal vascular appearance, bilateral
H35.021	Exudative retinopathy, right eye
H35.022	Exudative retinopathy, left eye
H35.023	Exudative retinopathy, bilateral
H35.061	Retinal vasculitis, right eye
H35.062	Retinal vasculitis, left eye
H35.063	Retinal vasculitis, bilateral
H35.051	Retinal neovascularization, unspecified, right eye

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inv-19: Macular degeneration, ROP, macular structural disordersICD-10Covered

H35.3111	Nonexudative age-related macular degeneration, right eye, early stage dry
H35.3112	Nonexudative age-related macular degeneration, right eye, intermediate dry stage
H35.3113	Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement
H35.3121	Nonexudative age-related macular degeneration, left eye, early dry stage
H35.3122	Nonexudative age-related macular degeneration, left eye, intermediate dry stage
H35.3123	Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement
H35.3131	Nonexudative age-related macular degeneration, bilateral, early stage dry
H35.3132	Nonexudative age-related macular degeneration, bilateral, intermediate dry stage
H35.3211	Exudative age-related macular degeneration, right eye with active choroidal neovascularization
H35.3212	Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization

inv-20: Retinal degenerations, detachments, edema, ischemiaICD-10Covered

H33.011	Retinal detachment with single break, right eye
H33.012	Retinal detachment with single break, left eye
H33.021	Retinal detachment with multiple breaks, right eye
H33.022	Retinal detachment with multiple breaks, left eye
H33.041	Retinal detachment with retinal dialysis, right eye
H33.051	Total retinal detachment, right eye
H33.311	Horseshoe tear of retina without detachment, right eye
H33.312	Horseshoe tear of retina without detachment, left eye
H33.331	Multiple defects of retina without detachment, right eye
H35.81	Retinal edema

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inv-21: Sickle-cell retinopathy and selected glaucoma/ocular hypertension codesICD-10Covered

H36.811	Nonproliferative sickle-cell retinopathy, right eye
H36.812	Nonproliferative sickle-cell retinopathy, left eye
H36.813	Nonproliferative sickle-cell retinopathy, bilateral
H36.821	Proliferative sickle-cell retinopathy, right eye
H36.822	Proliferative sickle-cell retinopathy, left eye
H36.823	Proliferative sickle-cell retinopathy, bilateral
H40.051	Ocular hypertension, right eye
H40.052	Ocular hypertension, left eye
H40.053	Ocular hypertension, bilateral

inv-22: Primary and specialty glaucoma staging codesICD-10Covered

H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage
H40.1121	Primary open-angle glaucoma, left eye, mild stage
H40.1122	Primary open-angle glaucoma, left eye, moderate stage
H40.1123	Primary open-angle glaucoma, left eye, severe stage
H40.1131	Primary open-angle glaucoma, bilateral, mild stage
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage
H40.1133	Primary open-angle glaucoma, bilateral, severe stage

inv-23: Angle-closure and secondary glaucomasICD-10Covered

H40.211	Acute angle-closure glaucoma, right eye
H40.212	Acute angle-closure glaucoma, left eye
H40.213	Acute angle-closure glaucoma, bilateral
H40.2211	Chronic angle-closure glaucoma, right eye, mild stage
H40.2212	Chronic angle-closure glaucoma, right eye, moderate stage
H40.2213	Chronic angle-closure glaucoma, right eye, severe stage

inv-24: Vitreous conditionsICD-10Covered

H43.01	Vitreous prolapse, right eye
H43.02	Vitreous prolapse, left eye
H43.11	Vitreous hemorrhage, right eye
H43.12	Vitreous hemorrhage, left eye
H43.13	Vitreous hemorrhage, bilateral
H43.821	Vitreomacular adhesion, right eye
H43.822	Vitreomacular adhesion, left eye
H43.823	Vitreomacular adhesion, bilateral

inv-25: Infectious, inflammatory, and degenerative myopia codesICD-10Covered

H44.021	Vitreous abscess (chronic) right eye
H44.022	Vitreous abscess (chronic) left eye
H44.023	Vitreous abscess (chronic) bilateral
H44.21	Degenerative myopia, right eye
H44.22	Degenerative myopia, left eye
H44.23	Degenerative myopia, bilateral

inv-26: Foreign body, hypotony, and related codesICD-10Covered

H44.711	Retained (nonmagnetic) (old) foreign body in anterior chamber, right eye
H44.712	Retained (nonmagnetic) (old) foreign body in anterior chamber, left eye
H44.713	Retained (nonmagnetic) (old) foreign body in anterior chamber, bilateral
H44.741	Retained (nonmagnetic) (old) foreign body in posterior wall of globe, right eye
H44.742	Retained (nonmagnetic) (old) foreign body in posterior wall of globe, left eye
H44.743	Retained (nonmagnetic) (old) foreign body in posterior wall of globe, bilateral
H44.411	Flat anterior chamber/hypotony of right eye

inv-27: ICD-10-CM Diagnosis Codes that Support Coverage Criteria — Extended listICD-10Covered

E13.3211	Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E13.3212	Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E13.3213	Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3292	Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E13.3293	Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3311	Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E13.3312	Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E13.3313	Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3391	Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E13.3392	Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

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Provider Actions and Billing Guidance

Documentation Required

Required documentation & diagnosis coding

Prior authorization and claims must reference an applicable ICD‑10‑CM diagnosis code from the list of covered diagnoses to support medical necessity for fundus photography. Photographs become part of the permanent medical record; fundus photos are usually taken through a dilated pupil unless dilation is unnecessary or clinically contraindicated.

Prior authorization/claim must include one of the ICD‑10‑CM codes listed in the policy.
Providers should document the applicable ICD‑10‑CM diagnosis code from the listed codes on the prior authorization and claim to support coverage.
Fundus photographs become part of the permanent medical record; document whether pupil dilation was performed or clinically contraindicated.

Prior Authorization

Prior authorization — diagnoses‑driven

Fundus photography is diagnoses‑driven for prior authorization and coverage: authorization will be considered when the documented diagnosis matches one of the medically indicated conditions enumerated in the policy. If the submitted diagnosis is not one of the listed supporting ICD‑10‑CM codes, the request or claim may not meet coverage criteria and is subject to denial or additional review.

Prior authorization decisions are based on documented diagnoses that meet the policy's coverage criteria.
Missing or unsupported diagnosis codes on a PA/claim may trigger denial or request for additional information.
Coverage follows the diagnoses listed and is reviewed annually; maintain current coding to reflect updates.

Denial Risk

Denial triggers & denial risk

Claims may be denied when fundus photography is performed for routine screening or replacement of a standard ophthalmoscopic exam, when the imaging is duplicative of other diagnostic procedures without providing new information, or when testing is repeated for stable/controlled disease without clinical change. Requests lacking a supported diagnosis code or adequate documentation are at increased risk for denial.

Not medically necessary when used as routine replacement of standard ophthalmoscopy.
Denial risk for duplicative documentation when no new clinical information is provided (e.g., concurrently with extended ophthalmoscopy or fluorescein angiography) .
Denial risk for repeated testing in controlled or stable disease without clinical indication.
Claims/PAs without a listed supporting ICD‑10‑CM code may be denied or returned for additional information.

Step Therapy

Screening considerations, step therapy & governance

Fundus photography should not be used as a general screening tool except for teleretinal diabetic evaluation when appropriate; no step therapy requirements apply for fundus photography under this policy. Follow Health Plan documentation, contractual, state and federal rules when submitting prior authorizations and claims.

Fundus photography is not a screening tool except for teleretinal diabetic evaluation when the patient is non‑compliant with in‑person diabetic eye exams.
No step therapy is specified for fundus photography in this policy.
Coverage and payment remain subject to plan terms, contracts, and applicable state/federal regulations.

Note

Provider action — scope & applicability

Operational note: This section lists the ICD‑10‑CM diagnosis codes that substantiate coverage for prior authorization and claims; provider action is limited to selecting and documenting the appropriate code(s) and supporting clinical information. This portion does not include additional provider operational instructions beyond coding and documentation requirements.

Provider action for this section: document the applicable ICD‑10‑CM diagnosis code from the list to support the PA/claim.
This section is not applicable for other operational instructions; see other provider‑facing sections for workflow details.

Definitions

inv-48: Fundus photography — definition and record use

Clinical useEmployed when photographic documentation is necessary for ongoing management of a specific ocular disease process; should not replace a thorough dilated fundus exam.

inv-49: Fundus autofluorescence — definition and clinical meaning

DefinitionFundus autofluorescence is an imaging modality where autofluorescent patterns arise from fluorophores (e.g., lipofuscin) and are modulated by absorbing elements such as melanin and rhodopsin and by other structures (vessels, lens).

Pathophysiology relevanceHyper-autofluorescence often reflects altered lipofuscin metabolism or unmasking of RPE signal (e.g., in Stargardt disease or geographic atrophy); hypo-autofluorescence can reflect RPE loss or blockage by anterior material (e.g., hemorrhage, fibrosis).

Clinical utilityPatterns of hyper- and hypo-autofluorescence have disease-specific mechanisms useful for diagnosis and monitoring of retinal disorders.

inv-50: Diabetic retinopathy codes — codes for types of diabetes with retinopathy and macular edema statuses

ScopeCodes include Type 1, Type 2, other specified, and drug/chemical-induced diabetes mellitus with nonproliferative and proliferative diabetic retinopathy and macular edema status.

Laterality and statusMany diabetes-related codes specify laterality (right/left/bilateral) and macular edema presence, resolution after treatment, or proliferative status (e.g., E10.*, E11.*, E13.*, E09.* series).

Use for coverageThese diabetic retinopathy codes are listed to support coverage of fundus photography when clinical criteria are met.

inv-51: Retinal detachment codes — retinal detachment subtypes covered in definitions

Included subtypesICD-10-CM entries cover retinal detachment subtypes such as detachment with single or multiple breaks, giant retinal tear, retinal dialysis, total detachment, serous detachment, and horseshoe tear without detachment.

LateralityMany retinal detachment codes specify laterality (right, left, bilateral) to align imaging with the affected eye.

Clinical relevanceThese detachment codes support use of fundus photography for documentation and management of retinal tear/detachment conditions.

inv-52: Retinal and macular diagnoses — retinal vascular occlusions, macular edema, neovascularization definitions

Retinal vascular occlusions & edemaCodes include arterial and venous occlusions (central, branch/tributary) and explicitly note macular edema or neovascularization where present (e.g., H34.* series, H34.8110 H34.8130).

Neovascularization & exudative diseaseEntries list retinal neovascularization, exudative retinopathies, hypertensive retinopathy, and other vascular retinal changes that guide monitoring and management.

Use with imagingThese retinal and macular diagnosis codes support the medical necessity of fundus photography for documenting vascular, ischemic, or macular pathology.

inv-53: Glaucoma diagnoses — glaucoma subtype and staging code definitions

Glaucoma subtypesICD-10-CM codes cover primary open-angle glaucoma, low-tension glaucoma, pigmentary glaucoma, capsular glaucoma with pseudoexfoliation, and angle-closure variants with staging distinctions (mild/moderate/severe).

Angle-closure & secondary glaucomasSeparate codes represent primary angle-closure, chronic angle-closure, intermittent angle-closure, and glaucoma secondary to trauma or inflammation with stage-specific codes.

Ocular hypertension and risk statesCodes include ocular hypertension and open-angle borderline findings (high/low risk), which may support imaging documentation when clinically indicated.

inv-54: Vitreous/foreign body/myopia diagnoses — vitreous conditions, foreign body, panuveitis, degenerative myopia definitions

Vitreous conditionsICD-10-CM entries include vitreous prolapse, vitreous hemorrhage, vitreous membranes/strands, vitreomacular adhesion, and other vitreous opacities (H43.* series).

Foreign body & hypotonyCodes list retained intraocular foreign bodies (magnetic and nonmagnetic) across anterior chamber, lens, vitreous, and posterior globe sites, as well as hypotony/flat anterior chamber (H44.* series).

Degenerative myopia & panuveitisDefinitions include degenerative myopia with maculopathy and inflammatory/panuveitis conditions that can require posterior segment imaging for management.

inv-55: Fundus photography (reference) — imaging of retina/posterior segment and monitoring uses (references AAO PPP)

Guideline referencesThe policy cites American Academy of Ophthalmology Preferred Practice Pattern guidance for retinal disorders and diabetic retinopathy as reference support for imaging indications and monitoring.

Monitoring useFundus photography is indicated for documentation and serial monitoring of retinal disease activity, treatment response, and progression when photographic documentation affects management.

OpenPayer

Clinical Policy: Fundus Photography

Coverage Criteria

Coding

Provider Actions and Billing Guidance

Background

Definitions