CurrentUnitedHealthcarePolicy CS378.B

Ocular Photoscreening Policy

Defines UnitedHealthcare's coverage position for instrument-based ocular photoscreening and retinal birefringence/polarization scanning including covered populations (children 1-5 years; individuals >=6 years with developmental delay unable to cooperate), not-covered populations (children <1 year and other individuals), applicable CPT codes and ICD-10 codes for developmental delay indications, and references/clinical evidence. Excludes specified states where separate state policies apply.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening Policy

Policy CodePolicy CS378.B

Change TypeUpdated application; supporting information clarified

Effective DateJune 1, 2025

Next Review Date

Key ActionDocument that the patient is aged 1-5 years (ending on 6th birthday) for mass screening, or for patients >=6 years document developmental delay and inability/unwillingness to cooperate with routine visual acuity screening to justify instrument-based photoscreening.

POLICY UPDATE CHANGES

Application section updated to remove Mississippi and to add Idaho and Kansas as states with separate policies.

Clinical Evidence section updated to reflect the most current information.

1-5 yrsPrimary covered pediatric age range

<1 yrNot covered (insufficient evidence)

>=6 yrs w/ delayCovered if unable/unwilling to cooperate

Coverage Summary

Scope: This policy (Policy Number CS378.B, STATUS: CURRENT) defines UnitedHealthcare's coverage position for instrument-based ocular photoscreening and retinal birefringence/polarization scanning. Effective date: June 1, 2025; Last review: July 1, 2025.

Overview: Instrument-based ocular photoscreening is covered as medically necessary when used as a mass screening instrument for children aged 1–5 years (ending on the 6th birthday), or for individuals aged 6 years and older with developmental delay who are unable or unwilling to cooperate with routine visual acuity screening. Instrument-based photoscreening is unproven and not medically necessary for other individuals, including children younger than 1 year of age. Retinal birefringence/retinal polarization scanning is considered unproven and not medically necessary for routine detection of eye misalignment/strabismus.

State application note: This Medical Policy does not apply to certain states with separate policies; as of the policy updates, Idaho and Kansas have state-specific ocular photoscreening policies. (Template update on 07/01/2025 removed prior language pertaining to Mississippi.)

Quick coverage facts — Ocular photoscreening

Primary covered pediatric age range1-5 years (ends on 6th birthday)

Not covered (insufficient evidence)<1 year

Covered if unable/unwilling to cooperate>=6 years with documented developmental delay

Procedure codes listed0469T, 99174, 99177 (3 codes)

Policy numberCS378.B

SubjectOcular photoscreening

Status / Effective / Last reviewCURRENT / 2025-06-01 / 2025-07-01

Medical-Necessity Criteria

Medically Necessary (Covered) - Instrument-based ocular photoscreening

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 / Excluded)

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

ANY of the following

Coding

Procedure Codes (reference)CPT

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

Diagnosis Codes Indicating Developmental Delay / Unable to CooperateICD-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

Document age and cooperation status

Document that the patient is aged 1-5 years (ending on 6th birthday) for mass screening, or for patients 6 years and older document developmental delay and inability/unwillingness to cooperate with routine visual acuity screening to justify instrument-based photoscreening.

Acceptable documentation: patient DOB/age in the chart and clinical notes indicating developmental delay or diagnosis code(s) supporting inability/unwillingness to cooperate (see listed ICD-10 codes for developmental delay/unable to cooperate).

Billing Rule

Use applicable procedure codes

Report the appropriate CPT code that corresponds to the device and analysis method (on-site vs remote) when submitting claims for ocular photoscreening.

0469T

Background & Evidence

Background: Ocular photoscreening collects and analyzes images of the eyes (digital or film) to detect amblyopia risk factors including refractive errors, strabismus, anisometropia, and media opacities by evaluating corneal light reflexes and fundus reflections; results are typically reported as pass/fail/repeat.

Utility: Instrument-based screening is particularly useful for young children and for individuals with developmental delays who cannot reliably perform optotype visual acuity testing; professional guidance (AAO and others) supports instrument-based techniques for children approximately 1–5 years and for older children unable to participate in optotype testing.

Retinal birefringence scanning: Retinal polarization scanning (retinal birefringence scanning, RBS) measures central fixation and has been proposed to detect strabismus, but current evidence is insufficient in quality and consistency to support routine coverage for detection of eye misalignment or strabismus.

Source	Key Point
USPSTF 2017	Moderate net benefit for vision screening ages 3-5; benefits uncertain for children <3
AAO 2022	Instrument-based screening useful for ages 1-5 and for older children unable to participate in optotype testing
Selected device studies	Multiple prospective and retrospective studies report high sensitivity/specificity for several photoscreeners but have limitations (single-center, small samples, varied populations)

Instrument-based ocular photoscreening: A method using digital or film imaging or automated refractors to detect amblyopia risk factors by analyzing light reflexes and fundus reflections; results are typically graded as pass, fail, or repeat.

Retinal birefringence scanning / Retinal polarization scanning: A method that measures central fixation by detecting birefringent properties of the retina; proposed for detecting strabismus but considered unproven for routine detection by this policy.

Revision History

2025-07-01template_updateLatest

Template Update removed content/language pertaining to the state of Mississippi; Supporting Information (Clinical Evidence) updated and previous policy version CS087.A archived.

2025-06-01application_update

Application section updated to indicate the policy does not apply to Idaho and Kansas (states have separate policies); previous policy version CS087.A archived.