ModifiedUnitedHealthcarePolicy CS378NJ.B

Ocular Photoscreening (New Jersey)

Policy governing instrument-based ocular photoscreening for New Jersey Medicaid members, specifying when photoscreening is considered medically necessary or not and listing applicable procedure and diagnosis codes.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening (New Jersey)

Policy CodePolicy CS378NJ.B

Change TypeContent updatesprior version archived

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionVerify plan/contract requirements and document screening results and personnel training when performing photoscreening.

SourceLink

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence section to reflect the most current information; previous policy version archived.

ages 1-5mass screening recommended age range (until 6th birthday)

>=6allowed for developmentally delayed or unable/unwilling to cooperate

0469T, 99174, 99177procedure codes listed

insufficient evidenceretinal birefringence scanning stance

Coverage Criteria for Ocular Photoscreening

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Medically Necessary

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

Medically necessary situations: (1) Individuals 6 years of age and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening; OR (2) As a mass screening instrument for children 1–5 years of age (ends on 6th birthday).

Unproven / Not Medically Necessary

Instrument-based ocular photoscreening is unproven and not medically necessary when ALL of the following apply:

Not medically necessary situations: (1) Individuals other than the groups specified as medically necessary; AND (2) Children less than 1 year of age due to insufficient evidence of safety and/or efficacy.

Retinal birefringence/polarization scanning (RBS)

Coverage stance for retinal birefringence/polarization scanning:

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

Recommended screening and follow-up

Instrument-based or visual acuity screening is recommended for children aged 36 to <72 months when meeting best-practice methods and follow-up provisions.

Recommended screening methods: Screen children aged 36 to <72 months annually (best practice) or at least once (acceptable minimum) during the interval between their third and sixth birthdays using either: (1) monocular visual acuity testing with appropriately scaled single crowded HOTV letters or LEA Symbols at a 5-ft (1.5-m) test distance (or calibrated 10-ft/3-m alternative) with pass criteria of 3 of 3 or 3 of 4 optotypes at 20/50 for ages 36–47 months and 20/40 for ages 48–<72 months; OR (2) instrument-based testing using autorefraction (Retinomax or SureSight in child mode programmed with VIP Study pass/fail criteria for 90% specificity).age 36 to <72 months; testing intervals annual or at least once

Children tested younger than 36 months: instrument-based screening can be used if available, with better success after ~18 months.

Acceptable supplemental/alternative devices: Use of the Plusoptix photoscreener is considered acceptable practice; adding the PASS stereoacuity test as a supplement is acceptable.

Fail/rescreen/referral actions:

Retinal birefringence scanning / retinal polarization

Retinal birefringence scanning (birefringent foveal scanning devices such as blinq and PVS):

Evidence summary: Existing evidence for retinal birefringence/retinal polarization devices (for example, blinq and the Pediatric Vision Scanner) is mixed and limited by small single-center studies, high-risk populations, and variable methodology; some individual studies report high sensitivity and specificity in select cohorts, but overall quality and generalizability are insufficient to support routine widespread use for screening.

Specific published studies include Bosque et al. (2021), Arnold (2020), Jost et al. (2014), and Nassif et al. (2006), which demonstrate promise but have limitations.

Instrument-based ocular photoscreening is considered unproven and not medically necessary for individuals who do not meet the policy’s specified medical necessity criteria. Specifically, when an individual does not fall into one of the groups identified as medically necessary (developmentally delayed persons >=6 years unable/unwilling to cooperate with routine visual acuity screening, or children aged 1–5 years as a mass screening population) the use of instrument-based photoscreening is not supported by this policy and is therefore not medically necessary.

Children who have received a comprehensive eye examination by an eye care professional within the prior 12 months do not require repeat photoscreening during that interval; documentation of the recent eye care exam should be used in lieu of routine screening.

Retinal birefringence scanning/retinal polarization scanning (RBS) is designated unproven and not medically necessary for the detection of eye misalignment or strabismus because current evidence does not adequately demonstrate safety and efficacy for these indications.

Overall, there is insufficient quality evidence to support routine use of retinal birefringence scanning devices for vision screening. Published studies are limited by small sample sizes, single-center designs, and application to high‑risk or referral populations, which prevents generalization to broad screening programs.

Procedure and Diagnosis Coding

Applicable Procedure CodesCPT

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

Applicable Diagnosis Codes (examples for development delay / inability 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.
Q90.0	Trisomy 21, non mosaicism (Down syndrome).
R62.0	Delayed milestone in childhood.

No codes listed in this sectionmixed

No codes listed

VIP Study specificity setting — 90% specificity (versions 2.24/2.25)

VIP Study specificity setting90% specificity using VIP Study pass/fail criteria (software versions 2.24 or 2.25) for SureSight/Retinomax in child mode

FormatSet in minus cylinder form per VIP Study guidance

Devices referencedApplied to Retinomax autorefractor or SureSight Vision Screener when programmed with VIP criteria

Visual acuity pass criteria (36–47 months)

Pass criteria (36–47 months)Correct identification of 3 of 3 or 3 of 4 optotypes at the 20/50 level for each eye

Optotypes recommendedAppropriately scaled logMAR single crowded HOTV letters or LEA Symbols surrounded by crowding bars

Test administrationChild matches or reads optotypes aloud at the specified test distance

Visual acuity pass criteria (48–<72 months)

Pass criteria (48–<72 months)Correct identification of 3 of 3 or 3 of 4 optotypes at the 20/40 level for each eye

Optotypes recommendedAppropriately scaled logMAR single crowded HOTV letters or LEA Symbols with crowding bars

FrequencyAnnual screening (best practice) or at least once between ages 3 and 5 per NCCVH guidance

Test distance for logMAR HOTV/LEA

Standard test distance5 ft (1.5 m) for logMAR HOTV/LEA testing (recommended)

Acceptable alternative10 ft (3 m) acceptable when using HOTV/LEA optotypes calibrated for that distance

Optotype configurationSingle crowded optotypes with surrounding crowding bars or single line with rectangular crowding bar on all four sides

Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Plan/Contract Verification Required

Verify plan, contract, and applicable federal/state requirements before billing. This Medical Policy is guidance; benefit coverage and reimbursement are governed by the member's specific plan, state mandates, and contractual terms. Providers should confirm prior authorization, coverage determinations, and member eligibility with UnitedHealthcare and review any state fee schedules (for example, New Jersey Medicaid) that may restrict reimbursement for specific codes.

Plan/contract verification required before billing or claim submission.
Policy is informational and does not guarantee payment or coverage.
Check state fee schedules for Medicaid programs (codes with asterisk may be excluded).

Billing Rule

Coding Inclusion Not Coverage Guarantee

Inclusion of procedure or diagnosis codes in this policy is for reference only and does not imply that the service is a covered benefit or that reimbursement will be provided. Coverage and payment are subject to the member's plan, state and federal law, and contractual terms.

Codes referenced (e.g., 0469T, 99174, 99177) are informational and not a guarantee of coverage.
Providers must verify coverage, coding, and reimbursement rules with the payer and applicable state programs.

Denial Risk

Direct Referral Triggers

Refer directly to an ophthalmologist or optometrist when specific triggers are present. Direct referral expedites comprehensive evaluation for children at higher risk for vision disorders.

Observable ocular abnormalities (e.g., strabismus, leukocoria) mandate direct referral.
Children with neurodevelopmental disorders or systemic conditions associated with ocular problems should be referred directly.
First-degree relatives with strabismus or amblyopia, history of prematurity (<32 weeks), or parental concern = direct referral.
Children who have had a comprehensive eye exam within the prior 12 months do not require screening.

Note

Service Description and Expected Outputs

Ocular photoscreening and retinal polarization scanning are instrument-based screenings that produce graded outputs (typical results: pass, fail, or repeat) and may include automated reports or remote analysis. Results should drive appropriate follow-up: passing results continue routine surveillance; failing or untestable results prompt rescreening or referral per guidance.

Photoscreening: image capture in darkened environment; analysis yields pass/fail/repeat.
Retinal polarization scanning (RBS): assesses central fixation, useful for detecting strabismus and some amblyopia.
Analysis may be on-site (0469T, 99177) or via remote review (99174), producing a report to guide referrals.

Documentation Required

Screening Program Documentation

Document training/certification of screeners, testing environment and equipment, and communication of results. Maintain records of referrals and outcomes as part of best-practice screening programs.

Record screener training/certification and date of competency.
Document test method, device used (e.g., Retinomax, SureSight, Plusoptix), and test environment (e.g., darkened room, distance).
Record screening results (pass/fail/repeat), date, and whether analysis was on-site or remote.
Document referrals to eye care professionals and any subsequent comprehensive eye exam results when available.
Rescreening plan for untestable children and timeline for referral if rescreening is not feasible.

Note

Rescreening / Referral Pathway

If a child is untestable or refuses testing, rescreen promptly — the same day or soon afterward — and no later than 6 months. Children who remain untestable due to cognitive, physical, or behavioral issues, or who cannot be rescreened in a timely manner, should be referred directly for a comprehensive eye exam.

Rescreen untestable children the same day or soon afterward, but no later than 6 months.
Refer directly when rescreening is unlikely or delayed due to the child's condition or administrative barriers.
Document attempts at rescreening and rationale for referral when applicable.

Note

Definitions

Ocular photoscreening

DefinitionOcular photoscreening uses images captured with a camera to assess refractive state, corneal light reflex position, and fundus reflection to detect amblyopia risk factors

ProcessImages are collected in a darkened room while the child looks at the camera; images may be analyzed onsite or sent to a central lab

OutputsResults are typically graded as pass, fail, or repeat

Retinal birefringence/retinal polarization scanning (RBS)

DefinitionRetinal birefringence/retinal polarization scanning (RBS) detects central fixation by measuring fixation of both eyes simultaneously to identify small- and large-angle strabismus

CharacteristicsNoninvasive technique that requires little patient cooperation and can be used in young children

Use caseApplied in pediatric ophthalmology screening to detect strabismus and certain forms of amblyopia

Instrument-based screening

DefinitionInstrument-based screening uses commercially available autorefractors, photoscreeners, or devices (e.g., Retinomax, SureSight, Plusoptix, Pediatric Vision Scanner/blinq) to detect amblyopia risk factors

Recommended devicesRetinomax and SureSight in child mode with VIP criteria; Plusoptix considered acceptable practice

Age and repeat testingCan be used at any age if available, with better success after 18 months; repeat annually through age 5 or until optotype acuity reliable

Untestable

DefinitionUntestable: children who are unable or refuse to complete testing

Risk and follow-upUntestable children are more likely to have vision problems and should be rescreened same day or soon after, but no later than 6 months; if rescreening not feasible, refer for comprehensive eye exam

Program implicationConsider direct referral for children with cognitive, physical, or behavioral issues likely to preclude rescreening

OpenPayer

Ocular Photoscreening (New Jersey)

Coverage Criteria for Ocular Photoscreening

Procedure and Diagnosis Coding

Provider Actions, Documentation, and Billing Guidance

Background and Rationale

Definitions