ModifiedUnitedHealthcarePolicy CS37OOH.B

Electroretinography (for Ohio Only)

UnitedHealthcare medical policy (Ohio only) governing coverage of multifocal electroretinogram (mfERG) and pattern electroretinogram (PERG/PERGLA), specifying medically necessary indications for mfERG and stating PERG/PERGLA as unproven/not medically necessary for coverage decisions. Includes applicable CPT/placeholder codes and guidance to follow federal/state/contractual requirements.

Policy Summary

PayerUnitedHealthcare

PolicyElectroretinography (for Ohio Only)

Policy CodePolicy CS37OOH.B

Change TypeMODIFIED

Effective DateJanuary 1, 2025

Next Review Date

Key ActionProvider must document one of the listed medically necessary indications in the medical record (e.g., history of long-term retinal-toxic drug use, hereditary retinal dystrophy, need to differentiate retinal vs optic nerve disease when visual field testing is inconclusive, or macular dystrophy).

POLICY UPDATE CHANGES

Added language specifying mfERG is medically necessary to differentiate retinal disease from optic nerve disease when visual field testing is inconclusive or cannot be performed reliably.

Added hereditary retinal dystrophies and macular dystrophies to the medically necessary indications for mfERG.

Replaced prior language that mfERG was proven and medically necessary for chloroquine and hydroxychloroquine retinopathy screening with broader wording: mfERG is proven and medically necessary 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).

Updated Clinical Evidence and References sections to reflect current literature through 2024.

4mfERG covered indications listed

Coverage Summary

This Ohio-specific UnitedHealthcare medical policy (Policy Number: CS37OOH.B) governs coverage of multifocal electroretinogram (mfERG) and pattern electroretinogram (PERG/PERGLA). It specifies medically necessary indications for mfERG and states that PERG/PERGLA are considered unproven and not medically necessary. The policy is effective January 1, 2025.

Key facts

Policy numberCS37OOH.B

PayerUnitedHealthcare

ScopeUnitedHealthcare medical policy (Ohio only) governing coverage of mfERG and PERG/PERGLA, specifying medically necessary indications for mfERG and stating PERG/PERGLA as unproven/not medically necessary

Effective dateJanuary 1, 2025

StatusMODIFIED

Has material changetrue

Medical Necessity Criteria

Multifocal Electroretinogram (mfERG) - Medically Necessary

mfERG is proven and medically necessary when ANY of the following indications are met:

ANY of the following

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)
Hereditary retinal dystrophies (e.g., birdshot chorioretinopathy or retinitis pigmentosa)
A need to differentiate retinal disease from optic nerve disease when visual field testing is inconclusive or cannot be performed reliably (e.g., advanced disease)
Macular dystrophies (e.g., Stargardt disease, Best disease, pattern dystrophy)

Coding

Applicable Procedure Codes (reference only)CPT

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

Provider Actions & Billing Impact

Documentation Required

Document indication for mfERG

Providers must document one of the listed medically necessary indications for mfERG in the medical record (for example: history of long-term retinal-toxic drug use, hereditary retinal dystrophy, need to differentiate retinal versus optic nerve disease when visual field testing is inconclusive or cannot be performed reliably, or macular dystrophy). Reference CPT code 92274 (mfERG).

Denial Risk

Potential denial for non-listed indications

Claims for mfERG for indications not listed as medically necessary (including macular degeneration, macular edema, epiretinal membrane, glaucoma, and other non-specified uses) may be denied as not medically necessary.

Background, Evidence, and Definitions

Electroretinography (ERG) tests measure retinal electrical responses to light stimuli; mfERG evaluates many local ERG responses (typically 61 or 103) within the central 30 degrees to assess macular and central retinal function. The policy recognizes mfERG as useful for detecting and monitoring macular dysfunction and for monitoring toxic retinopathy from systemic therapies.

Specifically, mfERG is designated medically necessary for: assessment of retinal health after long-term use of drugs known to cause retinal toxicity (examples include chloroquine, hydroxychloroquine, vigabatrin, ethambutol), for certain hereditary retinal dystrophies (for example, birdshot chorioretinopathy and retinitis pigmentosa), and for macular dystrophies (for example, Stargardt disease, Best disease, and pattern dystrophy). The policy also adds that mfERG may be medically necessary to differentiate retinal disease from optic nerve disease when visual field testing is inconclusive or cannot be performed reliably.

The evidence base cited includes systematic reviews and studies showing high sensitivity of mfERG for detection of antimalarial drug toxicity and utility in hereditary/macular dystrophies and other central retinal disorders. In contrast, PERG and PERGLA — which assess retinal ganglion cell activity using contrast-reversing pattern stimuli and an automated glaucoma-screening version, respectively — are considered unproven and not medically necessary due to insufficient evidence of clinical utility and impact on patient outcomes.

Label	Evidence statement
Sensitivity for HCQ/CQ toxicity (pooled, Tsang et al. 2015)
mfERG pooled sensitivity ~90% with variable specificity vs other modalities
Browning et al. 2014
mfERG sensitivity 92.9% and specificity 86.9% for HCQ/CQ retinopathy in small retrospective series

mfERG: Multifocal electroretinogram assesses many local ERG responses (typically 61 or 103) within the central 30 degrees to evaluate macular and central retinal function.

PERG / PERGLA: Pattern electroretinogram uses contrast-reversing pattern stimuli to assess macular retinal ganglion cell activity; PERGLA is an automated PERG optimized for glaucoma screening.

Revision History

01/01/2025addedLatest

Added language specifying mfERG is medically necessary to differentiate retinal disease from optic nerve disease when visual field testing is inconclusive or cannot be performed reliably.

01/01/2025added

Added hereditary retinal dystrophies and macular dystrophies to the medically necessary indications for mfERG (examples include birdshot chorioretinopathy, retinitis pigmentosa, Stargardt disease, Best disease, pattern dystrophy.

01/01/2025revised