Description

Ophthalmoscopy (also called funduscopy) is an examination of the fundus (back of the eye) using an instrument called an ophthalmoscope (or funduscope). Extended ophthalmoscopy may be used when abnormalities are observed during routine ophthalmoscopy and includes both the examination and a detailed drawing of the fundus with interpretation and report. It is generally reserved for suspected or known serious posterior segment pathology involving the macula, optic nerve or retina. The drawing is a necessary component to document findings obtained by the exam when fundus photography is inadequate. An extended ophthalmoscopy examination may include scleral indentation, which is the application of pressure using a depressor directly on the sclera or on the eyelid, in order to view the peripheral retina.

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Extended Ophthalmoscopy

Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0530-007

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Other methods for imaging or diagnosing conditions in the back of the eye include, but may not be limited to:

• Fluorescein Angiography – A procedure in which a fluorescent dye is injected into the bloodstream. The dye highlights the blood vessels in the back of the eye so they can be photographed. This may be used to assess adequacy of blood flow to the vessels in the back of the eye, identify leaking vessels or areas of ischemia (reduced blood flow) or to diagnose conditions such as diabetic retinopathy or macular degeneration.
• Fundus Autofluorescence – Imaging which documents the presence of mildly fluorescent light-sensing molecules contained in retinal photoreceptor cells. These molecules (fluorophores) accumulate in the cells and are stored as a substance called lipofuscin. High concentrations of lipofuscin has been linked to the loss of photoreceptor cells in the retina. During imaging, areas of high concentration of lipofuscin will be seen as hyperfluorescent, while hypofluorescence may occur when the retinal photoreceptor cells die or are absent. Standard fundus camera and confocal laser scanning ophthalmoscopy are the two most common modalities for recording autofluorescence.
• Fundus Photography – Involves the use of a specialized unit that consists of a microscope attached to flash-enabled camera with a high-powered lens designed to focus on the structures of the back of the eye (eg, macula, optic disk, optic nerve, retina, retinal blood vessels). Fundus photography can be performed with colored filters, or with specialized dyes including fluorescein and indocyanine green.

For information regarding confocal laser scanning ophthalmoscopy, optical coherence tomography (OCT), or scanning laser polarimetry, please refer to Scanning Computerized Ophthalmic Diagnostic Imaging Medical Coverage Policy.

Coverage Determination

Macula or Retina

Humana members may be eligible under the Plan for extended ophthalmoscopy of the macula or retina when the following criteria are met:

• Findings from routine ophthalmoscopy indicate the existence or high suspicion of one of the following macular or retinal conditions:

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Extended Ophthalmoscopy

Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0530-007

Page: 3 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Any mass (tumor) of the macula, retina or choroid; OR
• Congenital condition (eg, retinopathy of prematurity); OR
• Infection (bacterial, fungal, parasitic, viral); OR
• Inflammation (eg, pars planitis, uveitis); OR
• Macular pathology (eg, macular degeneration, macular hole); OR
• Myopic degeneration (eg, high myopia [ – 6.00 diopters or greater] with posterior myopia-specific pathology); OR
• Peripheral retinal pathology that increases the risk of retinal tear or detachment (eg, lattice degeneration); OR
• Retinal break (eg, hole, horseshoe tear, linear); OR
• Retinal detachment (eg, exudative, rhegmatogenous, tractional); OR
• Systemic disorders which may be associated with retinal pathology (eg, diabetic retinopathy); OR
• Trauma by blunt or penetrating injury to the eye or periorbital structures, including presence of a foreign body; OR
• Vascular (eg, retinal hemorrhage); AND all of the following:

• Further posterior segment anatomical study of the central or peripheral retina is required and expected to impact treatment; AND
• Information obtained via extended ophthalmoscopy is expected to add information not available via routine ophthalmoscopy; AND

Extended Ophthalmoscopy

Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0530-007

Page: 4 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

• Information obtained via extended ophthalmoscopy provides additive (nonduplicative) information to that available via other methods (eg, fluorescein angiography, fundus photography, optical coherence tomography, ultrasound)

Optic Nerve

Humana members may be eligible under the Plan for extended ophthalmoscopy of the optic nerve when the following criteria are met:

• Findings from routine ophthalmoscopy indicate the existence or high suspicion of one of the following optic nerve conditions:

• Any mass (tumor) of the optic nerve; OR
• Congenital condition (eg, optic nerve hypoplasia); OR
• Glaucomatous optic neuropathy; OR
• Infectious optic neuropathy (bacterial, fungal, parasitic, viral); OR
• Inflammation (eg, optic neuritis); OR
• Systemic disorders which may be associated with optic nerve pathology (eg, hyperthyroidism, systemic lupus erythematosus [SLE]); OR
• Trauma by blunt or penetrating injury to the eye or periorbital structures, including presence of a foreign body; OR
• Vascular (eg, ischemic optic neuropathy); AND all of the following:

• Further posterior segment anatomical study of the optic nerve is required and expected to impact treatment; AND
• Information obtained via extended ophthalmoscopy is expected to add information not available via routine ophthalmoscopy; AND

Extended Ophthalmoscopy

Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0530-007

Page: 5 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Information obtained via extended ophthalmoscopy provides additive (nonduplicative) information to that available via other methods (eg, fluorescein angiography, fundus photography, optical coherence tomography, ultrasound)

Coverage Limitations

Humana members may NOT be eligible under the Plan for extended ophthalmoscopy of the macula, optic nerve or retina for any indications other than those listed above including, but may not be limited to:

• Absence of a change in condition, signs or symptoms since the most recent prior exam using extended ophthalmoscopy; OR
• Conditions of the macula, optic nerve or retina which are fully visible and can be evaluated by routine ophthalmoscopy; OR
• Equivalent information has been obtained via alternative diagnostic or imaging methods; OR
• Normal clinical findings upon initial routine ophthalmoscopy; OR
• Routine monitoring of a condition or treatment response in the absence of signs or symptoms indicating a change; OR
• Routine monitoring of potential medication side effects in the absence of signs or symptoms indicating a change; OR
• When performed in conjunction with fundus photography or fluorescein angiography unless the information obtained via extended ophthalmoscopy is additive (nonduplicative) to that already available (eg, initial exam for staging of choroidal melanoma)

This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Extended Ophthalmoscopy

Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0530-007

Page: 6 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Note: Extended ophthalmoscopy examinations are generally expected to be required no more than three times per eye, per year. Extended ophthalmoscopy examinations in conjunction with either fundus photography or fluorescein angiography are generally considered not medically necessary.

Background

Additional information about eye conditions affecting the macula, optic nerve or retina may be found from the following websites:

• American Academy of Ophthalmology • National Eye Institute • National Library of Medicine

Medical Alternatives

Alternatives to extended ophthalmoscopy for evaluating or diagnosing eye conditions include, but may not be limited to, the following:

• Imaging (eg, fluorescein angiography, fundus photography, optical coherence tomography [OCT], ultrasound)

For information regarding OCT, please refer to Scanning Computerized Ophthalmic Diagnostic Imaging Medical Coverage Policy.

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.