CurrentUnitedHealthcarePolicy CS378NE.B

Ocular Photoscreening (for Nebraska Only)

Defines UnitedHealthcare's coverage position for instrument-based ocular photoscreening and retinal birefringence/polarization scanning for members in the State of Nebraska, including covered indications, not medically necessary indications, applicable procedure and diagnosis codes, and supporting evidence/guidelines.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening (for Nebraska Only)

Policy CodePolicy CS378NE.B

Change TypeSupporting Information Updated Clinical Evidence

Effective DateJune 1, 2025

Next Review Date

Key ActionThis Medical Policy applies only to the State of Nebraska; providers must confirm the member's state to apply this policy.

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence section to reflect the most current information.

2Primary covered populations (mass screening 1-5yrs; developmentally delayed >=6yrs)

1Excluded: children <1 year

3Referenced procedure codes

Coverage summary

Policy Quick Facts

Policy NumberCS378NE.B

Effective DateJune 1, 2025

Last ReviewJune 1, 2025

ScopeState of Nebraska policy defining coverage positions for instrument-based ocular photoscreening and retinal birefringence/polarization scanning, including covered and not medically necessary indications, applicable codes, and supporting evidence/guidelines.

Coverage stanceMixed — Instrument-based photoscreening: medically necessary for mass screening (ages 1–5) and for developmentally delayed individuals ≥6 years unable/unwilling to complete acuity testing; unproven/not medically necessary for other populations and for retinal birefringence/polarization scanning for detection of strabismus.

Medical necessity — criteria

Medically Necessary - Instrument-based ocular photoscreening

Instrument-based ocular photoscreening is proven and medically necessary when ANY of the following are met:

ANY of the following

Individuals 6 years of age and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening
As a mass screening instrument for children 1-5 years of age (must be performed before the child's 6th birthday)

Not Medically Necessary / Unproven - Photoscreening and RBS

Instrument-based ocular photoscreening or retinal birefringence/polarization scanning is unproven and not medically necessary when ALL of the following apply:

ALL of the following

All other individuals not meeting the medically necessary criteria above
Children less than 1 year of age (insufficient evidence of safety and/or efficacy)

Not Medically Necessary - Retinal birefringence scanning/retinal polarization scanning

Retinal birefringence scanning / retinal polarization scanning is unproven and not medically necessary for:

ALL of the following

Detection of eye misalignment or strabismus (insufficient evidence of safety and/or efficacy)

Procedure & diagnosis codes

Procedure codes referencedCPT

0469T	Retinal polarization scan; ocular screening with on-site automated results, bilateral
99174	Remote analysis and report
99177	Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with on-site analysis

Diagnosis / Condition codes referenced (developmental delay and related conditions)ICD-10

F70	Mild intellectual disabilities
F71	Moderate intellectual disabilities
F72	Severe intellectual disabilities
F73	Profound intellectual disabilities
F78.A1	SYNGAPI-related intellectual disability
F79	Unspecified intellectual disabilities
F80.0	Phonological disorder
F80.1	Expressive language disorder
F80.2	Mixed receptive-expressive language disorder
F80.4	Speech and language development delay due to hearing loss

1–10 of 98

1/10

Provider actions & documentation

Documentation Required

Verify member location applicability

This Medical Policy applies only to the State of Nebraska; providers must confirm the member's state to apply this policy.

Documentation Required

Confirm age and developmental status

Document patient's age and developmental delay or inability/unwillingness to cooperate with routine visual acuity testing when billing instrument-based photoscreening for members aged 6 years and older.

Document age and developmental delay or inability/unwillingness to cooperate with routine visual acuity testing.

Documentation Required

Mass screening age limits

For mass screening programs, ensure photoscreening is performed for children aged 1 through 5 years and stopped on the 6th birthday.

Affected procedure codes: 0469T, 99177, 99174
Age boundary: perform for ages 1-5; stop on the child's 6th birthday

Background & evidence

Ocular photoscreening collects and analyzes images captured with a camera to detect amblyopia risk factors, strabismus, high refractive errors, anisometropia, and media opacities; images are analyzed (on-site or remotely) and typically graded as pass, fail, or repeat. Retinal birefringence/polarization scanning (RBS) measures central fixation via birefringence properties and can detect small- and large-angle strabismus with minimal required patient cooperation. Current evidence supports instrument-based photoscreening for certain populations (mass screening of children aged 1–5 years and for developmentally delayed individuals ≥6 years who cannot cooperate with routine visual acuity testing), but RBS/retinal polarization scanning currently has insufficient quality evidence (mixed results, small single-center studies, and high-risk populations) to support routine coverage for detection of eye misalignment/strabismus.

Definitions

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening (for Nebraska Only)

Policy CodePolicy CS378NE.B

Change TypeSupporting Information Updated Clinical Evidence

Effective DateJune 1, 2025

Next Review Date

Key ActionThis Medical Policy applies only to the State of Nebraska; providers must confirm the member's state to apply this policy.

On This Page

OpenPayer

Ocular Photoscreening (for Nebraska Only)

Coverage summary

Medical necessity — criteria

Procedure & diagnosis codes

Provider actions & documentation

Background & evidence

Revision history