Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy

Policy ID: M-72-023

Section: Diagnostic Medical

Effective Date: May 01, 2020

Revised Date: November 16, 2024

Revision Effective Date: January 06, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

An United States Food and Drug Administration (U.S. FDA) approved digital imaging system is used to acquire a series of standard field color images and/or monochromatic images of the retina of each eye in the physician's office. These photos are then transmitted to a remote center for interpretation and recommendation for treatment by an ophthalmologist specialist for interpretation as well as recommendations for treatment.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date or

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Retinal telescreening with digital imaging and manual grading of images may be considered medically necessary as a screening technique for the detection of diabetic retinopathy.

Retinal tele-screening not meeting the criteria as indicated in this policy, is considered not medically necessary.

Procedure Codes

92227

92228

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Intraocular photography or digital retinal imaging with image interpretation by artificial intelligence software that is approved by the U.S. FDA may be considered medically necessary when used for the diagnosis of the following (not an all-inclusive list):

Macular degeneration
Retinal neoplasms
Choroid disturbances
Diabetic retinopathy
To identify Glaucoma
To identify Multiple sclerosis
To identify other central nervous system abnormalities.

Intraocular photography not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

92229

92250

Diagnosis Codes

Covered diagnosis codes for procedure codes 92227 and 92228

E08.8

E08.9

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.36

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.65

E08.69

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E09.8

E09.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.36

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.65

E09.69

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E10.8

E10.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.36

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.65

E10.69

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E11.8

E11.9

E11.00

E11.01

E11.21

E11.22

E11.29

E11.36

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.65

E11.69

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E13.8

E13.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.36

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.65

E13.69

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

Professional Statements and Societal Positions Guidelines

American Diabetes Association - 2023

In 2023, the American Diabetes Association updated its guidelines on standards of medical care for diabetes. Included in the guidelines were specific recommendations for initial and subsequent screening examinations for retinopathy:

People with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis.
If there is no evidence of diabetic retinopathy (DR) for one or more annual eye exams and glycemia is well controlled, then screening every 1-2 years may be considered. If any level of DR is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If DR is progressing or sight-threatening, then examinations will be required more frequently.
Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to DR screening can be appropriate screening strategies for DR. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated.
Promptly refer individuals with any level of diabetic macular edema, moderate or worse nonproliferative DR (a precursor of proliferative DR), or any proliferative DR to an ophthalmologist who is knowledgeable and experienced in the management of DR. A

ND Committee Review

Internal Medical Policy Committee 3-16-2020 added indications for Intraocular Photography 92250

Internal Medical Policy Committee 3-17-2021 wording changes and added Professional Statement and Societal Positions

Internal Medical Policy Committee 3-23-2022 Revision with coding updates - Effective April 01, 2022

Added procedure code 92229

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 11-19-2024 Revision - Effective January 06, 2025

Updated Professional Statements
removal of ' or' criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-72-022

Section: Diagnostic Medical

Effective Date: May 01, 2020

Revised Date: March 18, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: January 05, 2024

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Retinal tele-screening by digital imaging, for the detection and evaluation of diabetic retinopathy for individuals with diabetes mellitus may be considered medically necessary.

Retinal tele-screening not meeting the criteria as indicated in this policy, is considered not medically necessary.

Procedure Codes

92227

92228

Macular degeneration; or
Retinal neoplasms; or
Choroid disturbances; or
Diabetic retinopathy; or
To identify Glaucoma; or
To identify Multiple sclerosis; or
To identify other central nervous system abnormalities.

Intraocular photography not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

92229

92250

Diagnosis Codes

Covered diagnosis codes for procedure codes 92227 and 92228

E08.8

E08.9

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.36

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.65

E08.69

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E09.8

E09.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.36

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.65

E09.69

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E10.8

E10.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.36

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.65

E10.69

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E11.8

E11.9

E11.00

E11.01

E11.21

E11.22

E11.29

E11.36

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.65

E11.69

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E13.8

E13.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.36

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.65

E13.69

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

Professional Statements and Societal Positions Guidelines

American Diabetes Association - 2020

In 2020, the American Diabetes Association updated its guidelines on standards of medical care for diabetes. Included in the guidelines were specific recommendations for initial and subsequent screening examinations for retinopathy:

"Adults with type 1 diabetes should have an initial eye examination by an ophthalmologist or optometrist within five (5) years after the onset of diabetes. (B)"
"Individuals with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (B)"
"Eye examinations should occur before pregnancy or in the first trimester in individuals with pre-existing type 1 or type 2 diabetes, and then these individuals should be monitored every trimester and for one (1) year postpartum as indicated by the degree of retinopathy. (B)"
"If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then screening every 1–2 years may be considered. (B)"
"Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. (B)"

"Artificial intelligence systems that detect more than mild diabetic retinopathy and diabetic macular edema authorized for use by the FDA represent an alternative to traditional screening approaches. However, the benefits and optimal utilization of this type of screening have yet to be fully determined."

ND Committee Review

Internal Medical Policy Committee 3-16-2020 added indications for Intraocular Photography 92250

Internal Medical Policy Committee 3-17-2021 wording changes and added Professional Statement and Societal Positions

Internal Medical Policy Committee 3-23-2022 Revision with coding updates - Effective April 01, 2022

Added procedure code 92229

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy

Description

Policy Application

Criteria

Procedure Codes

Procedure Codes

Diagnosis Codes

Covered diagnosis codes for procedure codes 92227 and 92228

Professional Statements and Societal Positions Guidelines

American Diabetes Association - 2023

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer