UnitedHealthcare Ocular Photoscreening Policy Update

Coverage Criteria

Medically Necessary Indications

Covered when ALL of the following are met

Primary coverage criteria: Instrument-based ocular photoscreening is proven and medically necessary as a mass screening instrument for children 1-5 years of age (ends on 6th birthday) OR for individuals 6 years and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening.age and developmental status

See applicable developmental diagnoses and examples in coding section.

Unproven or Not Medically Necessary Indications

Not covered / unproven when ANY of the following apply

Unproven indications: 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.<1 year of age

Retinal birefringence (retinal polarization) scanning is also unproven for detection of eye misalignment/strabismus.

Routine preschool vision screening

Covered when ALL of the following are met (recommended practices):

Screening interval: Children aged 36 months to younger than 72 months should be screened annually (best practice) or at least once between their third and sixth birthdays.age 36 to <72 months

Exceptions for direct referral are listed below.

Acceptable screening methods: Use one of two best practice methods: (1) monocular visual acuity testing with appropriately scaled single crowded HOTV letters or LEA Symbols with crowding bars at 5 ft (or acceptable calibrated alternatives) meeting pass criteria; OR (2) instrument-based testing using Retinomax or SureSight set in child mode with VIP Study pass/fail criteria software v2.24 or v2.25 in minus cylinder form. Plusoptix is acceptable practice; PASS stereoacuity may supplement.device-specific

Other optotypes like Allen pictures and the Tumbling E should not be used.

Failure/untestable and direct referral criteria

Management following screening:

Fail or untestable: Children who fail screening should be referred for comprehensive eye examination by an optometrist or ophthalmologist. Children who are untestable should be rescreened the same day or soon afterward, but in no case later than 6 months; if rescreening is not feasible (cognitive, physical, behavioral, administrative barriers), refer directly for comprehensive examination.rescreen within 6 months

Document referral and subsequent comprehensive exam when failure occurs.

Direct referral conditions: Refer directly for comprehensive eye examination (do not screen) children with readily observable ocular abnormalities, neurodevelopmental disorders, systemic conditions associated with ocular abnormalities, first-degree relatives with strabismus or amblyopia, history of prematurity (<32 completed weeks), or parental concern. Children examined by an eye care professional within the prior 12 months need not be screened.prematurity <32 weeks

These exceptions are per NCCVH recommended practices.

Codes in the Applicable Codes table that are marked with an asterisk (*) are not listed on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program. Verify state Medicaid fee schedule eligibility before billing for services represented by those codes.

For monocular visual acuity testing in the preschool age group, use appropriately scaled (logMAR) single crowded HOTV letters or LEA Symbols with crowding bars at a 5-ft (1.5-m) test distance, with the child matching or naming optotypes aloud. A passing score is correct identification of 3 of 3 or 3 of 4 optotypes at 20/50 for children aged 36–47 months and at 20/40 for children aged 48 to <72 months. Do not use other optotypes such as Allen pictures or the Tumbling E for visual acuity testing in this age group.

Retinal birefringence scanning / retinal polarization scanning is considered unproven and not medically necessary for detecting eye misalignment or strabismus due to insufficient evidence of safety and efficacy.

Instrument-based photoscreening has high unreadable rates in very young infants; evidence shows particularly elevated unreadable results in children under 1 year of age. For this reason, instrument-based photoscreening is considered not medically necessary for children younger than 1 year.

FDA clearance or approval of a device alone does not establish coverage. This policy notes that ocular screening is a procedure and is not regulated by the FDA; FDA approval by itself is not a basis for coverage and coverage decisions are governed by applicable federal, state, and contractual benefit requirements.

Coding

Procedure Codes (referenced)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 (examples for development delay / unable 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.
G80.0	Spastic quadriplegic cerebral palsy.
Q90.0	Trisomy 21, non - mosaicism (meiotic nondisjunction).
R62.0	Delayed milestone in childhood.
Z91.198	Patient's noncompliance with other medical treatment and regimen for other reason.

Ages for screening

Annual screening (recommended)Children aged 36 months to younger than 72 months should be screened annually (best practice) or at least once between their third and sixth birthdays.

Instrument-based useful age rangeInstrument-based ocular photoscreening is proven and medically necessary as a mass screening instrument for children 1–5 years of age (ends on 6th birthday).

Not recommended under 1 yearInstrument-based photoscreening is not medically necessary for children less than 1 year of age due to high unreadable rates and insufficient evidence.

Provider Actions and Billing Guidance

Billing Rule

Referenced procedure codes and Louisiana Medicaid note

Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program. Applicable procedure codes referenced in this policy for ocular screening include: 0469T (retinal polarization scan, ocular screening with on-site automated results, bilateral), 99174 (instrument‑based ocular screening with remote analysis and report, bilateral), and 99177 (instrument‑based ocular screening with on‑site analysis, bilateral). Listing of a code in this policy does not itself imply coverage or guarantee payment; federal, state, or contractual benefit provisions govern coverage determinations.

Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and are not covered by Louisiana Medicaid.

Note

Coverage decision guidance

This Medical Policy is informational and intended to assist in interpreting UnitedHealthcare standard benefit plans. Coverage is determined by applicable federal, state, or contractual requirements; when there is a conflict, those requirements govern. Before applying this policy, verify the specific federal, state, or contractual benefit language that applies to the member.

Background

Ocular photoscreening collects and analyzes images of the eye to detect amblyopia risk factors such as refractive errors, strabismus, anisometropia, and media opacities with minimal patient cooperation. Results are typically reported as pass, fail, or repeat and can be analyzed on-site or remotely. Retinal polarization/birefringence scanning is a related technique intended to detect central fixation and strabismus with minimal cooperation but, per this policy, is considered unproven for detecting eye misalignment.

Definitions

Ocular photoscreening (definition)

DefinitionOcular photoscreening: collection and analysis of images captured with a digital or film camera to assess refractive state via patterns of reflected light; results typically graded as pass, fail, or repeat.

PurposeUsed to detect visual disorders that predispose children to amblyopia (refractive errors, strabismus, anisometropia, media opacities) with minimal cooperation.

ProcessImages taken in a darkened room while the child looks at the camera; images can be analyzed on-site or sent to a central laboratory for grading.

Retinal polarization scanning / RBS (definition)

DefinitionRetinal polarization scanning (retinal birefringence scanning, RBS): technique that measures retinal birefringence to detect central fixation of each eye, enabling detection of small- and large-angle strabismus.

OpenPayer

Ocular Photoscreening (for Louisiana Only)

Coverage Criteria

Coding

Provider Actions and Billing Guidance

Background

Definitions