Anthem Blue Cross Connecticut CG-MED-35 Retinal Telescreening Systems Form

This document addresses retinal telescreening in the outpatient setting, including its use for the detection of diabetic retinopathy.

Note: Please see the following related document for additional information:

• CG-MED-47 Fundus Photography

Clinical Indications

Medically Necessary:

Retinal telescreening systems in the outpatient setting are considered medically necessary for annual diabetic retinopathy screening as an alternative to retinopathy screening by an ophthalmologist or optometrist when both of the following criteria are met:

• The individual does not have prior known diabetic retinopathy; and
• The imaging and grading technique is performed with a U.S. Food and Drug Administration (FDA) approved device for retinal telescreening.

Not Medically Necessary:

All other uses of retinal telescreening systems in the outpatient setting are considered not medically necessary, including, but not limited to those listed below:

• To follow the progression of disease in individuals who have been diagnosed with diabetic retinopathy
• To screen or evaluate retinal conditions other than diabetic retinopathy, including, but not limited to macular degeneration.