CurrentUnitedHealthcarePolicy CS378NM.C

Ocular Photoscreening Nm Cs

UnitedHealthcare medical policy for instrument-based ocular photoscreening applicable only to New Mexico members, defining medically necessary indications, not medically necessary indications, description of services, evidence review, and applicable procedure and diagnosis codes listed for reference.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening Nm Cs

Policy CodePolicy CS378NM.C

Change TypeSupporting Information (clinical evidence & references updated)

Effective DateJun 1, 2026

Next Review Date

Key ActionPolicy applies only to New Mexico; providers must follow New Mexico-specific coverage determinations when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information.

2Medically necessary indications (children 1-5; ≥6 with developmental delay)

1Explicitly not covered population (children <1 year)

3Referenced procedure codes

numerousReferences cited

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This UnitedHealthcare medical policy addresses instrument-based ocular photoscreening for New Mexico members (state-specific application). It defines medically necessary indications (mass screening for children aged 1 to 5 years and individuals ≥6 years with developmental delay who cannot cooperate with routine visual acuity screening), not medically necessary uses, provides a description of services and referenced procedure/diagnosis codes, and summarizes supporting evidence. Policy number: CS378NM.C. Effective date: June 1, 2026. Coverage stance: mixed (proven/medically necessary for specified indications; unproven/not medically necessary for others, including retinal birefringence scanning).

Quick Facts

Medically necessary indications- Mass screening for children aged 1–5 (until sixth birthday) - Individuals ≥6 years with developmental delay unable/unwilling to cooperate with routine visual acuity screening

Not covered explicit populationChildren <1 year of age (insufficient evidence of safety/efficacy)

Referenced procedure codes0469T; 99174; 99177 (3 procedure codes referenced)

ReferencesSelect recent evidence: Oatts et al. 2025 systematic review; Ferreira et al. 2023 meta-analysis; Neena et al. 2022; Shah et al. 2021; policy effective 06/01/2026 update

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 to 5 years of age (ends on sixth birthday).
In individuals 6 years of age or older who have a developmental delay and are unable or unwilling to cooperate with routine visual acuity screening.

Not Medically Necessary / Unproven

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

Individuals not meeting the medically necessary criteria above (i.e., all other individuals).

Explicitly includes children less than 1 year of age due to insufficient evidence of safety and/or efficacy.

Retinal birefringence scanning/retinal polarization scanning

Retinal birefringence/retinal polarization scanning is described as:

Unproven and not medically necessary for the detection of eye misalignment or strabismus due to insufficient evidence of safety and/or efficacy.

Retinal birefringence scanning/retinal polarization scanning is not supported by sufficient quality evidence

Coding

Referenced Procedure Codes (for photoscreening / retinal polarization)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.

Referenced Diagnosis Codes (developmental delay / intellectual disabilities / related conditions)ICD-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.

1–10 of 108

1/11

Provider Actions

Documentation Required

State applicability documentation

This policy applies only to members in the state of New Mexico. Providers must follow New Mexico–specific coverage determinations when submitting claims and documentation.

Applies to New Mexico members

Billing Rule

Use appropriate procedure and diagnosis codes

When billing for photoscreening services, report the referenced CPT procedure codes and include supporting diagnosis codes that are consistent with developmental delay or other applicable conditions listed in the policy.

Affected procedure codes: 0469T, 99174, 99177
Include supporting diagnosis codes consistent with developmental delay or listed conditions

Documentation Required

Reference federal/state/contractual requirements

Before using this policy, check applicable federal, state, or contractual benefit plan requirements because those requirements govern in the event of a conflict with this standard policy.

Documentation Required

Use independent clinical judgment

This medical policy is provided for informational purposes and is intended to be used with the independent professional medical judgment of a qualified health care provider; it does not constitute medical advice or replace provider decision-making.

Background & Evidence

Ocular photoscreening involves collection and analysis of eye images (digital or film) based on photorefraction to detect risk factors for amblyopia, strabismus, and significant refractive errors; images are typically graded as pass, fail, or repeat and may be analyzed on-site or remotely.

Retinal birefringence scanning (also called retinal polarization scanning) measures retinal birefringence to detect central fixation and to identify small- and large-angle strabismus and certain amblyopia types; the method is noninvasive and requires little cooperation.

Retinal birefringence/retinal polarization scanning currently has insufficient quality evidence to support its use and is described in this policy as unproven and not medically necessary for detection of eye misalignment/strabismus due to mixed results, small sample sizes, and limited generalizability.

Reference	Summary/Key data
Oatts et al. (2025) systematic review	33 studies (level III); sensitivity range 32.3%–100%; specificity range 38.7%–94%; device-dependent accuracy (Plusoptix, Spot, Retinomax); referral rates reported in 21 studies varied 2.26%–63%; diagnostic accuracy dependent on device and study setting.
Ferreira et al. (2023) meta-analysis (<3 years)	Meta-analysis of 13 studies (n=64,041): referral rate 13% (95% CI 7%–19%); untestable rate 8% (95% CI 3%–15%); positive predictive value (PPV) 56% (95% CI 40%–71%); substantial heterogeneity across studies.
Neena et al. (2022)	Prospective study in children with neurodevelopmental disabilities (n=52) using Spot Vision Screener: sensitivity 96.5%, specificity 63.61%, PPV 80%, NPV 92.31%, AUC 79.9%; average age 10.5 years; ARF prevalence 73.1%.
Shah et al. (2021) PVS study	Prospective validation in 300 children (24–72 months): detected all 6 cases (sensitivity 100%, 95% CI 54%–100%); specificity 85% (95% CI 80%–89%); PVS referred 15% of screened children; median acquisition time 28 seconds.
Notable recent references	Additional cited sources and reviews include AAO 2022 guidance, AAPOS validation statements, USPSTF 2017 recommendations, Bosque/Blinq and other retinal birefringence studies; policy update noted 06/01/2026 (Supporting Information) updating clinical evidence and references.

Definitions

Instrument-based ocular photoscreening: Collection and analysis of eye images captured with a digital or film camera to detect visual disorders predisposing to amblyopia.

Retinal birefringence scanning / retinal polarization scanning: Method detecting central fixation by measuring birefringence of the retina; used to detect strabismus and certain amblyopia types.

ARF: Amblyopia risk factors.

Policy Summary

PayerUnitedHealthcare

PolicyOcular Photoscreening Nm Cs

Policy CodePolicy CS378NM.C

Change TypeSupporting Information (clinical evidence & references updated)

Effective DateJun 1, 2026

Next Review Date

Key ActionPolicy applies only to New Mexico; providers must follow New Mexico-specific coverage determinations when submitting claims.

SourceLink

On This Page

OpenPayer

Ocular Photoscreening Nm Cs

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Evidence

Definitions

Revision History