CurrentColorado Rocky Mountain Health PlansPolicy 2026T0660F

Ocular Photoscreening

This UnitedHealthcare Medical Policy defines coverage criteria for instrument-based ocular photoscreening (e.g., CPT 99174, 99177) and states that retinal birefringence/polarization scanning (e.g., CPT 0469T) is unproven; it applies to UnitedHealthcare Commercial and Individual Exchange plans and includes clinical background, guideline alignment, and applicable CPT codes for screening children and individuals with developmental delay.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOcular Photoscreening

Policy CodePolicy 2026T0660F

Change TypeSupporting information updated

Effective DateJune 1, 2026

Next Review Date

Key ActionConfirm coverage under the member-specific benefit plan and refer to the Preventive Care Services medical policy as applicable.

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version 2026T0660E.

2Primary covered scenarios

2Unproven / not medically necessary scenarios

3Key CPT/ICD groups listed

multipleReferences cited

Scope: This UnitedHealthcare Medical Policy (Policy Number 2026T0660F, effective June 1, 2026) defines coverage criteria for instrument-based ocular photoscreening (e.g., CPT 99174, 99177) and states that retinal birefringence/retinal polarization scanning (e.g., CPT 0469T) is considered unproven. It applies to UnitedHealthcare Commercial and Individual Exchange plans and includes clinical background, guideline alignment, and CPT/ICD groupings relevant to screening children and individuals with developmental delay.

Coverage stance (high level): The policy stance is mixed: instrument-based ocular photoscreening is medically necessary in specified situations but is unproven / not medically necessary in other scenarios.

Primary covered scenarios (2): 1) As a mass screening instrument for children aged 1 to 5 years (ends on sixth birthday); 2) In individuals 6 years or older with developmental delay who are unable or unwilling to cooperate with routine visual acuity screening.

Unproven / not medically necessary scenarios (2): 1) Instrument-based ocular photoscreening for all other individuals, including children under 1 year of age (insufficient evidence); 2) Retinal birefringence/retinal polarization scanning for detection of eye misalignment/strabismus (insufficient evidence).

Policy metadata

Policy Number2026T0660F

Effective Date2026-06-01

StatusCURRENT

Primary covered scenariosAs a mass screening instrument for children 1 to 5 years of age; in individuals ≥6 years with developmental delay unable/unwilling to cooperate with routine visual acuity screening

Unproven/not medically necessary scenariosInstrument-based photoscreening for all other individuals (including children <1 year); retinal birefringence/retinal polarization scanning for detection of strabismus/eye misalignment

Key CPT/ICD groups listedCPT: 99174, 99177 (covered); 0469T (retinal polarization scan - unproven); ICD-10: multiple developmental delay/intellectual disability and related codes (e.g., F70-F79, F80.*, F81.*, G80.*, Q90-Q99, etc.)

Medical-Necessity Criteria

Medically Necessary (Instrument-based ocular photoscreening)

Instrument-based ocular photoscreening is proven and medically necessary for the following:

Medically necessary scenarios

Mass screening - young children: As a mass screening instrument for children 1 to 5 years of age (ends on sixth birthday).
Individuals with developmental delay: In individuals 6 years of age or older who have a developmental delay and are unable or unwilling to cooperate with routine visual acuity screening.
See relevant developmental delay/ID diagnosis codes for documentation.

Coding

Covered / Instrument-based ocular screeningCPTCovered

99174	Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with remote analysis and report.
99177	Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with on-site analysis.

Listed / Retinal polarization scan (unproven according to policy)CPTExperimental

0469T

Retinal polarization scan, ocular screening with on-site automated results, bilateral

Relevant Diagnosis Codes (developmental delay / intellectual disabilities / related conditions)ICD-10

F70	Mild intellectual disabilities
F71	Moderate intellectual disabilities
F72	Severe intellectual disabilities
F73	Profound intellectual disabilities
F78.A1	SYNGAP1-related intellectual disability
F78.A9	Other genetic related intellectual disability
F79	Unspecified intellectual disabilities
F80.0	Phonological disorder
F80.1	Expressive language disorder
F80.2	Mixed receptive-expressive language disorder

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Provider Actions & Documentation

Documentation Required

Use member benefit and preventive care policy

Confirm coverage under the member-specific benefit plan and refer to the Preventive Care Services medical policy since many UnitedHealthcare plans cover CPT 99174 and 99177 as preventive care in certain circumstances.

99174
99177

Documentation Required

Age and cooperation criteria

Document patient's age and cooperation level; instrument-based photoscreening is supported for children age 1 to 5, and for individuals 6 years and older with developmental delay who cannot complete visual acuity testing; do not use for children <1 year.

99174
99177
do not use for children <1 year

Documentation Required

Reference member-specific benefit plan

When deciding coverage, reference the member-specific benefit plan document as it governs and may differ from the standard plan; check applicable federal or state mandates before using this policy.

Documentation Required

Medicare Advantage application

In absence of a Medicare NCD or LCD, Medicare Advantage plans may use this policy to create coverage determinations using objective evidence-based rationale per CMS guidance.

Documentation Required

Use of third-party tools

UnitedHealthcare may use third-party tools (e.g., InterQual criteria) to assist in administering benefits; policy is informational and does not constitute medical advice.

Background & Evidence

Instrument-based ocular photoscreening: a method that captures images of the eyes (photorefraction) to assess refractive state, corneal light reflex position, and fundus reflections to identify amblyopia risk factors (ARFs) such as refractive errors, strabismus, anisometropia, and media opacities; images may be analyzed on-site or remotely and yield pass/fail/repeat results.

Retinal birefringence / retinal polarization scanning: a noninvasive method that measures the retina’s birefringent/polarization properties to assess central fixation and binocularity; it can detect small- and large-angle strabismus and requires little cooperation, making it potentially useful in young children.

Utility in young children and those with developmental delay: instrument-based screening requires less cooperation than subjective visual acuity testing and is useful for assessing ARFs in children aged 1 to 5 years and in individuals aged 6 years or older with developmental delay who cannot complete optotype-based testing; retinal birefringence scanning also requires little cooperation but currently has mixed evidence and is considered unproven in this policy.

Instrument-based ocular photoscreening: Method for detection of visual impairments using images captured with a camera to assess refractive state, corneal reflex position, and fundus reflections to identify amblyopia risk factors; results are typically graded as pass, fail, or repeat.

Retinal birefringence scanning / retinal polarization scanning: Method for detecting central fixation/binocularity by measuring birefringent properties of the retina to identify strabismus and amblyopia; considered investigational/unproven in this policy due to insufficient quality evidence.

Amblyopia risk factors (ARFs): Conditions such as high refractive errors, anisometropia, strabismus, and media opacities that predispose to amblyopia.

Evidence Type	Summary
Systematic reviews/meta-analyses
Multiple systematic reviews and meta-analyses report variable sensitivity and specificity for instrument-based devices but support use for detecting amblyopia risk factors in young children while noting heterogeneity and limitations (e.g., Oatts et al. 2025; Ferreira et al. 2023; Zhang et al. 2019).
Retinal birefringence evidence
Studies of retinal birefringence/retinal polarization (e.g., Bosque 2021; Arnold 2020; Jost 2014) show mixed results with limitations including small, high-risk or single-center samples; policy considers retinal birefringence scanning unproven.
Recent evidence updates
Clinical evidence and references updated through 2025; AAPOS validation statement notes the novel birefringent device shows promise but overall evidence remains insufficient for routine coverage.

OpenPayer

Ocular Photoscreening

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Documentation

Background & Evidence

Revision History