CMS Ophthalmology: Extended Ophthalmoscopy and Fundus Photography Form

Summary Of Evidence

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Analysis of Evidence

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1. Abstract:

Fundus photography

Fundus photography uses a special camera to photograph structures behind the lens of the eye including the vitreous, retina, choroids, and optic nerve to document and follow disease processes of the eyes.

Extended ophthalmoscopy

Extended ophthalmoscopy is the detailed examination of the retina with a detailed drawing. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression.

It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina (macula, fundus, and periphery) large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination with interpretation and report. The examination must be used for medical decision making.

2. Indications:

Fundus photography

Fundus photography is not covered for routine screening.

In general, fundus photography is considered medically necessary only when it would assist in:

1. Monitoring potential progression of a disease process; or
2. Guidance in evaluating the need for or response to a specific treatment or intervention.

In other words, medical necessity for fundus photography should guide a clinical decision.

Therefore, baseline photos to document a condition that is reasonably expected to be static and/or not require future treatment would not be medically necessary. Such photos to provide a means of comparison to detect, for example, potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with “suspicious” areas, or a nevus or other tumor could be medically necessary.

Repeat fundus photography should only be performed at clinically reasonable intervals (i.e., consistent with a noted change on examination or after sufficient time has elapsed for progression or for a treatment to have reasonably had an impact).

Specific to this policy, fundus photography to guide a given treatment or intervention (vs. monitoring for progression) e.g., photos used to guide the placement of macular laser treatment or to monitor the response to intraocular vascular endothelial growth factor (VEGF) agents should only be ordered by the physician who actually performs the treatment or intervention.

Extended ophthalmoscopy

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions (THIS LIST MAY NOT BE EXHAUSTIVE):

a. Malignant neoplasm of the retina or choroid

b. Retained (old) intraocular foreign body, either magnetic or nonmagnetic

c. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration

d. Retinal detachment with or without retinal defect-the patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as “a curtain came down over my eyes.”

e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters)

f. Retinal defects without retinal detachment

g. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers-this may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation

h. Sudden visual loss or transient visual loss

i. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment

j. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye

k. Blunt injury to the eye or adnexa

l. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment)-spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders

m. Posterior scleritis-signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field

n. Vogt-Koyanagi-Harada syndrome- A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea

o. Degenerative disorders of the globe

p. Retinoschisis and retinal cysts-patients may complain of light flashes and floaters

q. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision

r. Glaucoma or is a glaucoma suspect-this may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve

s. Systemic disorders which may be associated with retinal pathology

t. High axial length myopia

u. Retinal edema

v. Metamorphopsia

w. High-risk medication for retinopathy or optic neuropathy

x. Choroidal nevus being evaluated for malignant transformation

y. Macular degeneration

3. Limitations:

If the study is performed as a screening service, it is not covered by Medicare.

Fundus photography

• All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary.
• Fundus photography of a normal retina will be denied as not medically necessary.

Extended ophthalmoscopy

• Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary.