UnitedHealthcare Ocular Photoscreening Coverage Update

Coverage Criteria — When Instrument-Based Ocular Photoscreening Is Covered

Medically necessary indications

Covered when ANY of the following are met:

Covered Indications: Mass screening: instrument-based ocular photoscreening as a mass screening instrument for children aged 1 through 5 years (ends on 6th birthday).age 1-5 years

Instrument-based photoscreening is indicated for population-based screening in this age range per policy.

Covered Indications: Individuals aged 6 years and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening.>=6 years with developmental delay and inability/unwillingness to cooperate

Instrument-based photoscreening may be used when standard optotype visual acuity testing is not feasible.

Recommended screening coverage criteria

Covered when ALL of the following are met:

Age: Child aged 36 months to younger than 72 months.36 to <72 months

Annual screening is best practice or at least once between 3rd and 6th birthdays per NCCVH recommendations.

Screening methods: Use one of two best-practice methods: (1) monocular visual acuity testing with single crowded HOTV letters or LEA Symbols (logMAR) at 5 ft with passing criteria (3 of 3 or 3 of 4 at 20/50 for 36–47 months; 20/40 for 48 to <72 months), OR (2) instrument-based testing using Retinomax or SureSight in child mode programmed with VIP Study pass/fail criteria (90% specificity). Plusoptix and PASS stereoacuity supplemental testing are acceptable practices.see NCCVH definitions and VIP criteria

Other optotypes (Allen pictures, Tumbling E) should not be used.

Rescreening and untestable: Children unable or refusing testing are considered untestable and should be rescreened the same day or soon afterward but no later than six months; those with cognitive, physical, or behavioral issues precluding rescreening or unable to be rescreened timely should be referred directly for a comprehensive eye examination.rescreen within 6 months

Not medically necessary / Unproven uses

Not covered / Unproven:

Unproven / Not Medically Necessary: Instrument-based ocular photoscreening is unproven and not medically necessary for all other individuals, including children less than 1 year of age, due to insufficient evidence of safety and/or efficacy.age <1 year or other non-specified indications

Policy explicitly states insufficient evidence for these uses.

Unproven / Not Medically Necessary: Retinal birefringence scanning/retinal polarization scanning (RBS) is unproven and not medically necessary for detection of eye misalignment or strabismus due to insufficient quality evidence.insufficient evidence

Existing studies are limited by small samples, high-risk populations, and single-center designs.

Device evidence summary

Informational: evidence and device evaluation

Retinal birefringence / PVS / blinq evidence: Current evidence for retinal birefringence/retinal polarization scanners (eg, blinq, Pediatric Vision Scanner/PVS) is mixed. Some studies report high sensitivity and specificity in selected or high-risk cohorts (Bosque 2021; Jost 2014; Loudon 2011), but limitations include small sample sizes, single-center settings, and enriched/high-risk populations. Overall, available studies do not provide sufficient quality evidence to support routine use for population screening.

AAPOS 2021 acknowledges novel bilateral birefringent foveal scanning shows promise but implementation evidence is limited.

Instrument-based ocular photoscreening is not medically necessary for children less than 1 year of age because of insufficient evidence of safety and/or efficacy. The policy specifies that instrument-based photoscreening is considered proven and medically necessary only for mass screening of children aged 1 through 5 years (ending on the 6th birthday) or for individuals aged 6 years and older who are developmentally delayed and unable or unwilling to cooperate with routine visual acuity screening. Retinal birefringence (retinal polarization) scanning is also stated as unproven and not medically necessary for detection of eye misalignment or strabismus.

For visual acuity testing in the relevant pediatric age groups, use appropriately scaled single crowded HOTV letters or LEA Symbols with crowding bars at a five-foot (1.5 m) test distance. The policy explicitly states that other optotypes such as Allen pictures and the Tumbling E should not be used for visual acuity testing in this age group.

Instrument-based ocular photoscreening is considered unproven and not medically necessary for all other individuals not meeting the covered indications. This includes children less than 1 year of age and any other population for which there is insufficient evidence of safety or efficacy to support routine use.

Retinal birefringence (retinal polarization) scanning currently lacks sufficient high-quality evidence to support its routine use for screening or detection of strabismus or eye misalignment. The literature includes mixed results derived from small, single-center or high-risk cohorts; therefore the policy designates retinal birefringence scanning as unproven and not medically necessary for detection of eye misalignment or strabismus.

Coding — Procedure and Diagnosis Codes

Applicable procedure CPT/HCPCS CodesCPT

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.

Applicable diagnosis codes (examples for development delay / unable/unwilling to cooperate)ICD-10

F70	Mild intellectual disabilities.
F71	Moderate intellectual disabilities.
F72	Severe intellectual disabilities.
F73	Profound intellectual disabilities.
F79	Unspecified intellectual disabilities.
F80.0	Phonological disorder.
F84.0	Autistic disorder.
G80.0	Spastic quadriplegic cerebral palsy.
Q90.9	Down syndrome, unspecified.
R62.0	Delayed milestone in childhood.

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Provider Actions — Billing, Documentation, and Referral

Prior Authorization

Prior authorization / coding reference

Prior authorization may be required by the member's benefit plan. The following procedure codes are provided for billing/coding reference only; inclusion does not guarantee coverage. Verify prior authorization requirements with UnitedHealthcare or the applicable benefit plan before ordering or billing these services.

0469T — Retinal polarization scan, ocular screening with on-site automated results, bilateral (reference only).
99174 — Instrument-based ocular screening, bilateral; with remote analysis and report (reference only).
99177 — Instrument-based ocular screening, bilateral; with on-site analysis (reference only).
Listing of codes is for reference; check the member's plan and authorization portal for current prior authorization and billing rules.

Note

Check benefit plan requirements

Benefit coverage is determined by the federal, state, and contractual requirements that apply to the member’s plan. Before using this policy, check the governing benefit documents and any state-specific or contractual mandates. Do not assume standard policy language overrides plan- or jurisdiction-specific rules.

Definitions and Test Criteria

inv-20: Ocular photoscreening — definition and method summary

DefinitionOcular photoscreening is a method that collects and analyzes images of the eyes captured with a digital or film camera to detect visual disorders that can predispose children to amblyopia; results are typically graded as pass, fail, or repeat.

Method summaryImages are obtained in a darkened room while the child looks at the camera; analysis uses patterns of light reflected through the pupil, corneal light reflex position, and fundus reflections to assess refractive state and fixation and to detect strabismus.

Workflow optionsPhotographs may be analyzed on-site or sent to a central laboratory for review by ophthalmologists or trained personnel.

Target conditions detectedDetects risk factors for amblyopia, strabismus, high refractive errors, anisometropia, and media opacities by assessing fixation and reflex patterns.

inv-21: Retinal birefringence/retinal polarization scanning (RBS) — definition and intended use

Background — Clinical Context

Ocular photoscreening uses noninvasive image capture and automated analysis to identify risk factors that can lead to amblyopia, including strabismus, high refractive error, anisometropia, and media opacities. The goal of screening is early identification and referral so that amblyopia-related conditions can be treated promptly to improve visual outcomes. Retinal birefringence scanning is a related technique that attempts to detect central fixation and strabismus with minimal cooperation, but current evidence is limited and mixed.

Revision History

06/01/2025revisionLatest

Archived previous policy version CS378KY.01 and updated Clinical Evidence section to reflect the most current information.

OpenPayer

Ocular Photoscreening (for Kentucky Only)