Download Medical Policy Retinal Telescreening for Diabetic

Medical Policy
Retinal Telescreening for Diabetic Retinopathy
Table of Contents
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Policy: Commercial

Coding Information

Information Pertaining to All Policies

Policy: Medicare

Description

References

Authorization Information

Policy History
Policy Number: 065
BCBSA Reference Number: 9.03.13
Related Policies

Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions, #401
Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Screening for retinopathy in diabetics performed by ophthalmologists or optometrists using conventional
fundus photography OR digital retinal imaging technology may be considered MEDICALLY NECESSARY
when all of the following criteria are met:
 The individual does not have prior known diabetic retinopathy; and
 The imaging technique covers a total retinal area which includes the Diabetic Retinopathy Study
 seven-standard fields (DRS7); and
 Use does not exceed one study, utilizing either method, per member, per provider, per year.
Screening for retinopathy in diabetics ordered by non-eye care professionals using digital retinal imaging
technology may be considered MEDICALLY NECESSARY when all of the following criteria are met:
 The individual does not have prior known diabetic retinopathy; and
 The imaging technique covers a total retinal area which includes the Diabetic Retinopathy Study
 seven-standard fields (DRS7); and
 Use does not exceed one study per member per provider per year.
Note: Digital retinal imaging can be performed through either a dilated or undilated pupil.
Retinal telescreening is INVESTIGATIONAL for all other indications, including the monitoring and
management of disease in individuals diagnosed with diabetic retinopathy.
Medicare HMO BlueSM and Medicare PPO BlueSM Members
Local Coverage Determination (LCD): Ophthalmology: Posterior Segment Imaging (Extended
Ophthalmoscopy and Fundus Photography) (L25466)
1
http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=25466&ContrId=292&ver=58&ContrVer=1&Date=02%2f26%2f2014&DocID=L25466
&bc=iAAAAAgAAAAAAA%3d%3d&
Prior Authorization Information
Commercial Members: Managed Care (HMO and POS)
Prior Authorization is NOT required.
Commercial Members: PPO, and Indemnity
Prior Authorization is NOT required.
Medicare Members: HMO BlueSM
Prior Authorization is NOT required.
Medicare Members: PPO BlueSM
Prior Authorization is NOT required.
CPT Codes / HCPCS Codes / ICD-9 Codes
The following codes are included below for informational purposes. Inclusion or exclusion of a code does
not constitute or imply member coverage or provider reimbursement. Please refer to the member’s
contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an
individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is
included below for your reference.
Providers should report all services using the most up-to-date industry-standard procedure, revenue, and
diagnosis codes, including modifiers where applicable.
CPT Codes
CPT codes:
92227
92228
92250
Code Description
Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with
diabetes) with analysis and report under physician supervision, unilateral or bilateral
Remote imaging for monitoring and management of active retinal disease (e.g.,
diabetic retinopathy) with physician review, interpretation and report, unilateral or
bilateral
Fundus photography with interpretation and report
ICD-9 Diagnosis Codes
ICD-9-CM
diagnosis
codes:
250.50
250.51
250.52
250.53
362.01
362.02
362.03
362.04
362.05
362.06
362.07
Code Description
Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
uncontrolled
Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as
uncontrolled
Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled
Background diabetic retinopathy
Proliferative diabetic retinopathy
Nonproliferative diabetic retinopathy NOS
Mild nonproliferative diabetic retinopathy
Moderate nonproliferative diabetic retinopathy
Severe nonproliferative diabetic retinopathy
Diabetic macular edema
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ICD-10-CM Diagnosis Codes
ICD-10-CM
diagnosis
codes:
E08.311
E08.319
E08.321
E08.329
E08.331
E08.339
E08.341
E08.349
E09.311
E09.319
E09.321
E09.329
E09.331
E09.339
E09.341
E09.349
E08.351
E08.359
E09.351
E09.359
E10.311
E10.319
E10.321
E10.329
E10.331
E10.339
Code Description
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with
macular edema
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy
without macular edema
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic
retinopathy with macular edema
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic
retinopathy without macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic
retinopathy with macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic
retinopathy without macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic
retinopathy with macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with
macular edema
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy
without macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic
retinopathy without macular edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with
macular edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy
without macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with
macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy
without macular edema
Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular
edema
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular
edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with
macular edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without
macular edema
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E10.341
E10.349
E10.351
E10.359
E10.36
E10.39
E11.311
E11.319
E11.321
E11.329
E11.331
E11.339
E11.341
E11.349
E11.351
E11.359
E11.39
E11.65
E13.311
E13.319
E13.321
E13.329
E13.331
E13.339
E13.341
E13.349
E13.351
E13.359
E13.36
E13.39
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular
edema
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without
macular edema
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema
Type 1 diabetes mellitus with diabetic cataract
Type 1 diabetes mellitus with other diabetic ophthalmic complication
Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular
edema
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular
edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with
macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without
macular edema
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular
edema
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without
macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
Type 2 diabetes mellitus with other diabetic ophthalmic complication
Type 2 diabetes mellitus with hyperglycemia
Other specified diabetes mellitus with unspecified diabetic retinopathy with macular
edema
Other specified diabetes mellitus with unspecified diabetic retinopathy without macular
edema
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with
macular edema
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without
macular edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy
with macular edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy
without macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with
macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy
without macular edema
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular
edema
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular
edema
Other specified diabetes mellitus with diabetic cataract
Other specified diabetes mellitus with other diabetic ophthalmic complication
Description
Diabetic retinopathy is the leading cause of blindness among adults aged 20–74 years in the United
States. The major risk factors for developing diabetic retinopathy are duration of diabetes and severity of
hyperglycemia. After 20 years of disease, almost all patients with type 1 and greater than 60% of patients
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with type 2 diabetes will have some degree of retinopathy. Other important risk factors include
hypertension and elevated serum lipid levels.
Diabetic retinopathy progresses, at varying rates, from asymptomatic, mild nonproliferative abnormalities
to proliferative diabetic retinopathy (PDR), with new blood vessel growth on the retina and posterior
surface of the vitreous. The 2 most serious complications for vision are diabetic macular edema and PDR.
Although proliferative disease is the main blinding complication of diabetic retinopathy, macular edema is
more frequent and is the leading cause of moderate vision loss in people with diabetes.
The value of screening is well-established, since diabetic retinopathy has few visual or ocular symptoms
until vision loss develops. With early detection, diabetic retinopathy can be treated with modalities that
can decrease the risk of severe vision loss. Diabetic retinopathy telescreening is a diagnostic test, which
uses a digital fundus camera and the internet to transmit digital images of the retina to another location
for evaluation by trained readers. Screening can be performed in the medical doctor’s office rather than
having to make an additional appointment. Results are sent back to the medical doctor’s office with
recommendations for follow-up with an eye specialist if necessary.
Examples of digital camera and transmission systems for diabetic retinopathy telescreening include the
Diabetic Retinopathy Digital Disease Detection and Tracking System from Inoveon Corp., DigiScope®
from EyeTel Corp., and the Fundus AutoImagerä from Visual Pathways Inc. All retinal telescreening for
diabetic retinopathy are considered investigational regardless of the commercial name, the manufacturer
or FDA approval status except when used for the medically necessary indications that are consistent with
the policy statement.
Summary
A number of studies have reported on the agreement regarding the presence and stage of retinopathy
based on ophthalmoscopy versus photography or standard film versus digital imaging. The studies
generally found a high level of agreement between retinal examination and imaging. Several studies
suggested that retinal imaging through a dilated pupil was equivalent or superior to ophthalmic
examination regarding the detection of diabetic retinal changes. Although evidence indicates that digital
imaging without mydriasis leads to an increase in the proportion of ungradable photographs, practice
guidelines and clinical input supports the use of both dilated and undilated retinal telescreening. At this
time, it is unclear whether nonspecialist photographers would evaluate undilated photographs at the
point-of-care and, if needed, repeat photography with dilation.
Overall, the published medical literature is adequate to conclude that digital imaging systems are safe
and effective alternatives to the gold standard of dilated indirect ophthalmoscopy coupled with
biomicroscopy or stereoscopic fundus photography. Additional advantages of digital imaging systems
include short examination time and the ability to perform the test in the primary care physician setting.
Automated scoring also has the potential to improve screening in the primary care setting, and several
automated scoring systems are being evaluated. Although the sensitivity of these systems to rule out
disease appears to be high, the moderate specificity indicates there are a substantial number of false
positive results, implying that positive results would need to be confirmed by referral to and examination
by appropriate specialists.
Policy History
Date
6/2014
1/2014
11/20114/2012
2/2012
2/2010
Action
Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015.
New references added from BCBSA National medical policy.
Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
Reviewed - Medical Policy Group - Psychiatry and Ophthalmology.
No changes to policy statements.
Reviewed - Medical Policy Group - Psychiatry and Ophthalmology.
No changes to policy statements.
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2/2009
9/2008
1/2014
Reviewed - Medical Policy Group - Psychiatry and Ophthalmology.
No changes to policy statements.
New policy, effective 9/2008, describing covered and non-covered indications.
New references added from BCBSA National medical policy.
Information Pertaining to All Blue Cross Blue Shield Medical Policies
Click on any of the following terms to access the relevant information:
Medical Policy Terms of Use
Managed Care Guidelines
Indemnity/PPO Guidelines
Clinical Exception Process
Medical Technology Assessment Guidelines
References
1. Garg S, Davis RM. Diabetic retinopathy screening update. Clinical Diabetes; 27(4) 140-5 Available
online at: http://clinical.diabetesjournals.org/content/27/4/140.full. Last accessed September, 2013.
2. American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010;
33 Suppl 1:S11-61 2010. Available online at:
http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html. Last accessed
September, 2013.
3. Early Treatment Diabetic Retinopathy Study Research Group. Fundus photographic risk factors for
progression of diabetic retinopathy. ETDRS report number 12. . Ophthalmology 1991; 98(5
Suppl):823-33.
4. Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic retinopathy from
stereoscopic color fundus photographs--an extension of the modified Airlie House classification.
ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group.
Ophthalmology 1991; 98(5 Suppl):786-806.
5. Moss SE, Klein R, Kessler SD et al. Comparison between ophthalmoscopy and fundus photography
in determining severity of diabetic retinopathy. Ophthalmology 1985; 92(1):62-7.
6. Kinyoun JL, Martin DC, Fujimoto WY et al. Ophthalmoscopy versus fundus photographs for
detecting and grading diabetic retinopathy. Invest Ophthalmol Vis Sci 1992; 33(6):1888-93.
7. Delori FC, Gragoudas ES, Francisco R et al. Monochromatic ophthalmoscopy and fundus
photography. The normal fundus. Arch Ophthalmol 1977; 95(5):861-8.
8. Liesenfeld B, Kohner E, Piehlmeier W et al. A telemedical approach to the screening of diabetic
retinopathy: digital fundus photography. Diabetes Care 2000; 23(3):345-8.
9. Tennant MT, Greve MD, Rudnisky CJ et al. Identification of diabetic retinopathy by stereoscopic
digital imaging via teleophthalmology: a comparison to slide film. Can J Ophthalmol 2001; 36(4):18796.
10. Fransen SR, Leonard-Martin TC, Feuer WJ et al. Clinical evaluation of patients with diabetic
retinopathy: accuracy of the Inoveon diabetic retinopathy-3DT system. Ophthalmology 2002;
109(3):595-601.
11. Rudnisky CJ, Hinz BJ, Tennant MT et al. High-resolution stereoscopic digital fundus photography
versus contact lens biomicroscopy for the detection of clinically significant macular edema.
Ophthalmology 2002; 109(2):267-74.
12. Heaven CJ, Cansfield J, Shaw KM. The quality of photographs produced by the non-mydriatic
fundus camera in a screening programme for diabetic retinopathy: a 1 year prospective study. Eye
(Lond) 1993; 7 ( Pt 6):787-90.
13. Peters AL, Davidson MB, Ziel FH. Cost-effective screening for diabetic retinopathy using a
nonmydriatic retinal camera in a prepaid health-care setting. Diabetes Care 1993; 16(8):1193-5.
14. 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.
15. 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.
16. Murgatroyd H, Ellingford A, Cox A et al. Effect of mydriasis and different field strategies on digital
image screening of diabetic eye disease. Br J Ophthalmol 2004; 88(7):920-4.
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17. Sanchez CI, Niemeijer M, Dumitrescu AV et al. Evaluation of a computer-aided diagnosis system for
diabetic retinopathy screening on public data. Invest Ophthalmol Vis Sci 2011; 52(7):4866-71.
18. Oliveira CM, Cristovao LM, Ribeiro ML et al. Improved automated screening of diabetic retinopathy.
Ophthalmologica 2011; 226(4):191-7.
19. Abramoff MD, Folk JC, Han DP et al. Automated analysis of retinal images for detection of referable
diabetic retinopathy. JAMA Ophthalmol 2013; 131(3):351-7.
20. Fong DS, Aiello L, Gardner TW et al. American diabetes association position statement: retinopathy
in diabetes. Diabetes Care 2004; 27:S84-S87.
21. Handelsman Y, Mechanick JI, Blonde L et al. American Association of Clinical Endocrinologists
Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan.
Endocr Pract 2011; 17 Suppl 2:1-53.
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Diabetic Retinopathy. 2012. Available online at: http://www.aao.org/ppp. Last accessed September,
2013.
23. American Academy of Ophthalmology. Diabetic Retinopathy, Preferred Practice Pattern. 2003.
24. American Academy of Ophthalmology. American Academy of Ophthalmology Clinical Statement.
Screening for diabetic retinopathy. 2012. Available online at:
http://one.aao.org/CE/PracticeGuidelines/ClinicalStatements_Content.aspx?cid=ed55ed3c-b34b4f10-ae13-09e063d8d773. Last accessed September, 2013.
25. American Academy of Ophthalmology. American Academy of Ophthalmology Clinical Statement:
Screening for Retinopathy in the Pediatric Patient with Type 1 Diabetes Mellitus. 2008. Available
online at: http://one.aao.org/CE/PracticeGuidelines/ClinicalStatements.aspx. Last accessed
September, 2013.
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2013.
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