Currentsierra health and lifePolicy 2025T0651C

Electroretinography (mfERG, PERG/PERGLA) Coverage Criteria

Defines medical necessity and coverage stance for multifocal electroretinogram (mfERG) and pattern electroretinogram (PERG/PERGLA) testing for UnitedHealthcare Commercial and Individual Exchange plans; who may order and clinical indications covered.

Policy Summary

Payersierra health and life

PolicyElectroretinography (mfERG, PERG/PERGLA) Coverage Criteria

Policy CodePolicy 2025T0651C

Change TypeTemplate update / shared policy creation

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionCheck the member-specific benefit plan for prior authorization requirements and verify coverage before submitting for mfERG or PERG/PERGLA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Proven mfERG indications

2Procedure codes listed

UnprovenPERG/PERGLA stance

90%/52%mfERG sensitivity (pooled)

Coverage Criteria

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Proven / Medically Necessary Indications for mfERG

mfERG is medically necessary for the following indications:

mfERG covered indications: To assess the health of the retina in patients following long term use of drugs known to cause retinal toxicity (e.g., chloroquine, hydroxychloroquine, vigabatrin, ethambutol)

from policy proven indications

mfERG covered indications: When a need exists to differentiate retinal disease from optic nerve disease when visual field testing is inconclusive or cannot be performed reliably (e.g., advanced disease)

from policy proven indications

mfERG covered indications: Hereditary retinal dystrophies (e.g., birdshot chorioretinopathy or retinitis pigmentosa)

from policy proven indications

mfERG covered indications: Macular dystrophies (e.g., Stargardt disease, Best disease, pattern dystrophy)

from policy proven indications

Unproven / Not Medically Necessary

Not medically necessary / unproven uses:

mfERG not medically necessary: mfERG is unproven and not medically necessary for all other indications not listed as proven, including but not limited to macular degeneration, macular edema, epiretinal membrane, and glaucoma due to insufficient evidence

from policy

PERG/PERGLA not medically necessary: Pattern electroretinogram (PERG) and PERGLA are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy

from policy

Evidence-informed clinical utility statements

Clinical evidence and guideline positions relevant to utility of mfERG and PERG/PERGLA

mfERG utility: mfERG can identify localized central/macular retinal dysfunction, may detect toxic retinopathy, and can be useful when full-field ERG is normal; accuracy may be limited with unstable fixation and small local abnormalities can be missed by mfERG or by fdOCT in different cases

Supported by Dale et al. 2010, Lai et al. 2007, AAO 2022, IFCN 2010

PERG utility and limitations: PERG/PERGLA may detect retinal ganglion cell dysfunction (changes in waveform amplitude or latency) in conditions such as glaucoma and diabetes, but available evidence is low quality and clinical utility for changing management or improving long-term outcomes has not been established

Supported by ECRI, Hayes assessment (2021, updated 2024), and observational studies

Technical consideration: Accurate fixation is a pre-requisite for clinically meaningful mfERG and PERG recordings; lack of standardized reference ranges and disagreement between structural (fdOCT) and functional (mfERG) tests limit interpretation

Consistent with IFCN, ISCEV, and comparative studies

The policy distinguishes between multifocal electroretinogram (mfERG) and pattern electroretinogram (PERG/PERGLA). mfERG is defined in the policy as medically necessary for a limited set of indications (to assess retinal health after long‑term use of drugs known to cause retinal toxicity; to differentiate retinal from optic nerve disease when visual field testing is inconclusive or unreliable; for hereditary retinal dystrophies; and for macular dystrophies). By contrast, PERG and PERGLA are designated unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

When considering electrophysiologic testing for glaucoma assessment, note that the American Academy of Ophthalmology (AAO) Preferred Practice Pattern for primary open‑angle glaucoma (POAG) does not specifically recommend ERG as a diagnostic tool. An AAO technology assessment also identified issues that have prevented adoption of ERG for routine glaucoma evaluation; therefore ERG (including PERG/PERGLA) is not endorsed as a standard diagnostic modality for POAG in the AAO guidance.

The policy explicitly states that PERG and PERGLA are unproven and not medically necessary because the evidence is insufficient to support their safety or efficacy. It further clarifies that mfERG is not medically necessary for indications other than those listed as proven (for example, age‑related macular degeneration, macular edema, epiretinal membrane, and glaucoma are specifically noted as noncovered indications when not among the listed proven uses).

Available evidence does not demonstrate that PERG testing leads to management changes that improve patient outcomes. Reviews and technology assessments (including ECRI and a Hayes HTA) conclude that while PERG/PERGLA can detect waveform changes consistent with retinal ganglion cell dysfunction, the current evidence is low quality and lacks proof that earlier detection via PERG results in earlier effective interventions or improved long‑term health outcomes.

Provider Actions & Billing

Documentation Required

Member-specific benefit plan governs

The member-specific benefit plan governs coverage determinations. Verify the member's plan document for coverage limits, exclusions, and any applicable federal or state mandates; in case of conflict, the member-specific benefit plan controls.

Check member-specific benefit plan document for coverage and limitations
Follow federal/state mandates that may require coverage

Documentation Required

Documentation and applicable guidance

Before ordering or submitting for services, check the member-specific benefit plan and any applicable guidance (federal/state mandates, Medicare NCD/LCD). Policies may be subject to change and other guidelines (e.g., InterQual) may be used to administer benefits.

Verify whether Medicare NCD/LCD guidance applies for Medicare Advantage members
Confirm any state-mandated coverage requirements prior to authorization or billing

Definitions

Multifocal electroretinogram (mfERG) — definition and typical stimulus array

Typical stimulus arraymfERG assesses many localized ERG responses, typically using a 61- or 103-element stimulus array covering the central 30 degrees.

Primary purposeMaps local retinal (central/macular) function by recording multiple localized ERG responses to detect focal macular dysfunction.

Test typeObjective electrophysiologic recording of retinal electrical responses to patterned light stimuli across multiple retinal locations.

Pattern electroretinogram (PERG) / PERGLA — definition and purpose

Stimulus and target cellsPERG uses contrast-reversing pattern stimuli to assess macular retinal ganglion cell (RGC) activity.

PERGLA variantPERGLA is a fully automatic version of the PERG optimized for glaucoma screening.

Clinical roleIntended to detect RGC dysfunction (changes in waveform amplitude and latency), but evidence for impact on patient outcomes is limited.

mfERG — concise definition as an objective electrophysiologic test mapping local retinal function

Concise definitionmfERG is an objective electrophysiologic test that records and maps local retinal (especially macular) function by analyzing response amplitudes and implicit times across multiple retinal locations.

Clinical utilityUseful for detecting localized central retinal dysfunction when full-field ERG is normal and for monitoring toxic retinopathy from systemic therapies.

Technical considerationAccurate fixation during recording is a pre-requisite to obtain clinically meaningful mfERG data.

PERG / PERGLA — retinal ganglion cell response components and clinical context

Physiologic focusPERG measures retinal ganglion cell responses (typical waveform components include P50 and N95) using pattern-reversal stimuli.

Clinical contextEmployed to assess RGC dysfunction in conditions such as glaucoma and diabetic retinal disease, though comparisons with other diagnostics and impact on outcomes are uncertain.

Standards guidanceISCEV and other expert bodies recognize PERG (and mfERG) for assessing macular dysfunction severity and occult maculopathy, with technical standards informing interpretation.

0509T	Electroretinography (ERG) with interpretation and report, pattern (PERG).
92274	Electroretinography (ERG), with interpretation and report; multifocal (mfERG)

OpenPayer

Electroretinography (mfERG, PERG/PERGLA) Coverage Criteria

Coverage Criteria

Coding

Provider Actions & Billing

Background

Definitions