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Medical Policy: 09.03.08
Original Effective Date: July 2008
Reviewed: May 2012
Revised: September 2008
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Digital imaging systems use a digital fundus camera to acquire a series of standard field color images and/or monochromatic images of the retina of each eye. While this type of retinopathy screening and risk assessment is proposed as an alternative to conventional dilated fundus examination it is not considered a substitute for a comprehensive ophthalmologic examination. The digital images that are captured are electronically transmitted to a remote location where they are evaluated by trained non-physician technicians and/or ophthalmology specialists. Additionally, digital images may be stored for comparison with subsequent images. This approach to screening and detection of diabetic retinopathy may be most useful in certain geographic areas where access to an ophthalmologist or optometrist is restricted.
The American Diabetes Association recommends retinopathy screening with yearly retinal examinations beginning at the time of diagnosis of diabetes mellitus for all persons age 30 years and older. For persons under age 30 years, annual retinal examinations are recommended beginning within 3-5 years after diagnosis of diabetes mellitus once the person is 10 years or older.
The value of screening for diabetic retinopathy is well established. Diabetic retinopathy has few visual or ocular symptoms until vision loss develops. Because treatments are aimed at preventing vision loss, and retinopathy can be asymptomatic, it is important to detect disease and begin treatment early in the process.
The literature indicates this technology has not been shown to be effective at detecting and quantifying the range of other ophthalmologic pathology that can accompany diabetic retinopathy, including cataract and glaucoma which are more common in patients with diabetes. These technologies are not to be considered a substitute for a comprehensive eye evaluation by an ophthalmologist experienced in managing retinopathy in a patient with diabetes. When Digital Retinal Imaging Systems are used as the primary mode of screening, seven field stereoscopic imaging with interpretation by an ophthalmologist is recommended. Glaucoma screening and anterior chamber exam should also be performed for age appropriate individuals.
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Prior Approval:
Not applicable
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Policy:
Digital imaging systems as a means to screen for and initially detect diabetic retinopathy in persons with an established diagnosis of diabetes mellitus may be considered medically necessary.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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S0625 – retinal telescreening by digital imaging of multiple different fundus areas to screen for vision-threatening conditions, including imaging, interpretation and report.
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92227 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral
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92228 Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral
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92250 Fundus photography with interpretation and report
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Selected References:
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American Diabetes Association. Position statement: Standards of Medical Care in Diabetes–2008. Diabetes Care. 2008 Jan;31 Suppl 1:S12-S54.
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Chun DW, Bauer RM, Ward TP et al. Evaluation of digital fundus images as a diagnostic method for surveillance of diabetic retinopathy. Mil Med. 2007 Apr;172(4):405-10.
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AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists Medical Guidelines For Clinical Practice For The Management Of Diabetes Mellitus. Endocr Pract. 2007 May-June;13 Suppl 1:1-68.
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Ahmed J, Ward TP, Bursell SE et al. The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy. Diabetes Care. 2006 Oct;29(10):2205-9.
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Ruamviboonsuk P, Teerasuwanajak K, Tiensuwan M et al. Interobserver agreement in the interpretation of single-field digital fundus images for diabetic retinopathy screening. Ophthalmology. 2006 May;113(5):826-32.
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Wei JC, Valentino DJ, Bell DS et al. A Web-based telemedicine system for diabetic retinopathy screening using digital fundus photography. Telemed J E Health. 2006 Feb;12(1):50-7.
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Wilson C, Horton M, Cavallerano J et al. Addition of primary care-based retinal imaging technology to an existing eye care professional referral program increased the rate of surveillance and treatment of diabetic retinopathy. Diabetes Care. 2005; 28(2):318-22.
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Scanlon PH, Malhotra R, Thomas G et al. The effectiveness of screening for diabetic retinopathy by digital imaging photography and technician ophthalmoscopy. Diabet Med 2003;20(6):467-74.
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Ciulla TA, Amador AG, Zinman B. Diabetic Retinopathy and Diabetic Macular Edema. Diabetes Care 2003 Sep;26(9):2653-6.
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Bragge P, Gruen RL, Chau M, et al. Screening for Presence or Absence of Diabetic Retinopathy: A Meta-analysis. Arch Ophthalmol 2011; 129(4):435-44.
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Policy History:
Date Reason Action
June 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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