CurrentUnitedHealthcarePolicy CS378ID.A

Ocular Photoscreening (for Idaho Only)

State-specific UnitedHealthcare medical policy (Idaho, including Idaho Medicaid Plus) defining when instrument-based ocular photoscreening and retinal birefringence/polarization scanning are considered medically necessary or not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening (for Idaho Only)

Policy CodePolicy CS378ID.A

Change TypeNew Medical Policy (state-specific)

Effective DateJun 1, 2025

Next Review Date

Key ActionPolicy applies only to the state of Idaho, including Idaho Medicaid Plus plans; providers must follow applicable federal, state, or contractual benefit requirements which govern coverage when conflicting.

POLICY UPDATE CHANGES

New Medical Policy effective 06/01/2025.

2Medically necessary indications listed

2Unproven / Not medically necessary categories

3Key CPT/HCPCS codes referenced

Coverage Summary

This state-specific UnitedHealthcare medical policy for Idaho (Policy Number CS378ID.A) addresses ocular photoscreening and related technologies; it became effective June 1, 2025. The policy defines a mixed coverage stance: instrument-based ocular photoscreening is considered medically necessary in specified situations but other uses and certain technologies (e.g., retinal birefringence/polarization scanning) are considered unproven/not medically necessary under this policy.

Key policy dates and quick facts

Effective dateJune 1, 2025

Last reviewJune 1, 2025

Policy numberCS378ID.A

Scope summaryState-specific UnitedHealthcare medical policy (Idaho, including Idaho Medicaid Plus) defining when instrument-based ocular photoscreening and retinal birefringence/polarization scanning are considered medically necessary or not medically necessary.

Medically necessary indications listed2

Unproven / Not medically necessary categories2

Key CPT/HCPCS codes referenced3 (0469T, 99174, 99177)

Medical-Necessity Criteria

Medically Necessary (Proven) Uses

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

ANY of the following

As a mass screening instrument for children 1-5 years of age (ends on 6th birthday).
In individuals 6 years of age and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening.

Not Medically Necessary / Unproven

Instrument-based ocular photoscreening or specific technologies are unproven and not medically necessary when ALL of the following apply:

ALL of the following

Instrument-based ocular photoscreening for all other individuals not described as medically necessary, including children less than 1 year of age, due to insufficient evidence of safety and/or efficacy.
Retinal birefringence scanning/retinal polarization scanning for detection of eye misalignment or strabismus due to insufficient evidence of safety and/or efficacy.

Coding

Referenced Procedure CodesCPT

0469T	Retinal polarization scan, ocular screening with on-site automated results, bilateral.
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.

Referenced Diagnosis / High-Risk / Developmental Delay CodesICD-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 Required

State-specific application

Policy applies only to the state of Idaho, including Idaho Medicaid Plus plans; providers must follow applicable federal, state, or contractual benefit requirements which govern coverage when conflicting.

Policy applies to Idaho, including Idaho Medicaid Plus; providers must follow applicable federal, state, or contractual benefit requirements.

Background and Definitions

Ocular photoscreening involves capturing and analyzing images of the eyes to detect amblyopia risk factors such as strabismus, high refractive errors, anisometropia, and media opacities; it is based on photorefraction and assessment of corneal light reflex and fundus reflections to infer fixation and misalignment. The policy notes that retinal polarization/birefringence scanning (RBS) evaluates central fixation and can detect strabismus with minimal patient cooperation, but current evidence is insufficient to support routine coverage of RBS for detection of eye misalignment or strabismus.

Term	Definition
Instrument-based ocular photoscreening	Method for detection of visual impairments using images of the eyes captured with a digital or film camera, analyzed to identify amblyopia risk factors.
Retinal birefringence scanning / retinal polarization scanning	Technique to detect central fixation and potential strabismus by measuring birefringent properties of the retina; considered investigational in this policy.

Source	Summary
USPSTF 2017	Moderate net benefit for vision screening in children aged 3-5 years; benefits for children younger than 3 years are uncertain.
AAO 2022	Recommends instrument-based screening useful for children 1-5 years and for developmentally delayed older children who cannot cooperate with optotype testing.