Criteria
Electroretinography used to diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions may be considered medically necessary for ANY ONE of the following indications (This is not an all-inclusive list):
- Toxic retinopathies, including those caused by intraocular metallic foreign bodies, Vigabatrin and Chlorpromazine; or
- Diabetic retinopathy; or
- Retinal vascular disease (e.g., Central Retinal Artery Occlusion [CRAO], Transient Retinal Artery Occlusion, Central Retinal Vein Occlusion [CRVO], Branch Vein Occlusion [BVO], and sickle cell retinopathy) ; or
- Autoimmune retinopathies (e.g., Cancer Associated Retinopathy [CAR], Melanoma Associated Retinopathy [MAR], and Acute Zonal Occult Outer Retinopathy [AZOOR]) ; or
- Retinal detachment; or
- Assessment of retinal function after trauma (e.g., vitreous hemorrhage, dense cataracts, macula scars and other conditions where the fundus cannot be visualized) ; or
- Retinitis pigmentosa and related hereditary degenerations; or
- Retinitis punctata albescens; or
- Leber's congenital amaurosis; or
- Choroideremia; or
- Gyrate atrophy of the retina and choroid; or
- Goldman-Favre syndrome; or
- Congenital stationary night blindness; or
- X-linked juvenile retinoschisis; or
- Achromatopsia; or
- Cone dystrophy; or
- Disorders mimicking retinitis pigmentosa; or
- Usher Syndrome; or
- Retinal Dystrophies (e.g., Stargardt's disease, Fundus Flavimaculata, North Carolina macular dystrophy, Best's Vitelliform dystrophy, Sorsby's macular dystrophy).
mfERG may be considered medically necessary to detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity.
Electroretinography not meeting the criteria as indicated in this policy, is considered not medically necessary.
ALL forms of electroretinography (ERG, fERG, mfERG, and PERG) for either diagnosis or management of glaucoma are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
