Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

LCD Information Document Information Source LCD ID N/A LCD ID L33467 Original ICD-9 LCD ID Not Applicable LCD Title Ophthalmology: Extended Ophthalmoscopy and Fundus Photography Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 05/11/2023 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.42 CFR §410.32(a) indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §80.6 Intraocular Photography 42 CFR §411.15(k)(1) indicates coverage exclusion for any services that are not reasonable and necessary for the following purpose: For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Coverage Indications, Limitations, and/or Medical Necessity 1. Abstract: Fundus photography Fundus photography uses a special camera to photograph structures behind the lens of the eye including the vitreous, retina, choroids, and optic nerve to document and follow disease processes of the eyes. Extended ophthalmoscopy Extended ophthalmoscopy is the detailed examination of the retina with a detailed drawing. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression.It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina (macula, fundus, and periphery) large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination with interpretation and report. The examination must be used for medical decision making. 2. Indications: Fundus photographyFundus photography is not covered for routine screening. In general, fundus photography is considered medically necessary only when it would assist in:1. Monitoring potential progression of a disease process; or 2. Guidance in evaluating the need for or response to a specific treatment or intervention.In other words, medical necessity for fundus photography should guide a clinical decision. Therefore, baseline photos to document a condition that is reasonably expected to be static and/or not require future treatment would not be medically necessary. Such photos to provide a means of comparison to detect, for example, potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with “suspicious” areas, or a nevus or other tumor could be medically necessary.Repeat fundus photography should only be performed at clinically reasonable intervals (i.e., consistent with a noted change on examination or after sufficient time has elapsed for progression or for a treatment to have reasonably had an impact).Specific to this policy, fundus photography to guide a given treatment or intervention (vs. monitoring for progression) e.g., photos used to guide the placement of macular laser treatment or to monitor the response to intraocular vascular endothelial growth factor (VEGF) agents should only be ordered by the physician who actually performs the treatment or intervention.Extended ophthalmoscopyAn extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions (THIS LIST MAY NOT BE EXHAUSTIVE):a. Malignant neoplasm of the retina or choroidb. Retained (old) intraocular foreign body, either magnetic or nonmagneticc. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degenerationd. Retinal detachment with or without retinal defect-the patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as “a curtain came down over my eyes.”e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters)f. Retinal defects without retinal detachmentg. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers-this may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferationh. Sudden visual loss or transient visual lossi. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachmentj. Penetrating wound to the orbit resulting in the retention of a foreign body in the eyek. Blunt injury to the eye or adnexal. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment)-spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disordersm. Posterior scleritis-signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual fieldn. Vogt-Koyanagi-Harada syndrome- A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nauseao. Degenerative disorders of the globep. Retinoschisis and retinal cysts-patients may complain of light flashes and floatersq. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision r. Glaucoma or is a glaucoma suspect-this may be evidenced by increased intraocular pressure or progressive cupping of the optic nerves. Systemic disorders which may be associated with retinal pathologyt. High axial length myopiau. Retinal edemav. Metamorphopsiaw. High-risk medication for retinopathy or optic neuropathyx. Choroidal nevus being evaluated for malignant transformationy. Macular degeneration 3. Limitations:If the study is performed as a screening service, it is not covered by Medicare. Fundus photography All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary. Fundus photography of a normal retina will be denied as not medically necessary. Extended ophthalmoscopy Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

1. Abstract: Fundus photography Fundus photography uses a special camera to photograph structures behind the lens of the eye including the vitreous, retina, choroids, and optic nerve to document and follow disease processes of the eyes. Extended ophthalmoscopy Extended ophthalmoscopy is the detailed examination of the retina with a detailed drawing . It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression. It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina (macula, fundus, and periphery) large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination with interpretation and report . The examination must be used for medical decision making. 2. Indications: Fundus photography Fundus photography is not covered for routine screening. In general, fundus photography is considered medically necessary only when it would assist in: 1. Monitoring potential progression of a disease process; or 2. Guidance in evaluating the need for or response to a specific treatment or intervention. In other words, medical necessity for fundus photography should guide a clinical decision. Therefore, baseline photos to document a condition that is reasonably expected to be static and/or not require future treatment would not be medically necessary. Such photos to provide a means of comparison to detect, for example, potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with “suspicious” areas, or a nevus or other tumor could be medically necessary. Repeat fundus photography should only be performed at clinically reasonable intervals (i.e., consistent with a noted change on examination or after sufficient time has elapsed for progression or for a treatment to have reasonably had an impact). Specific to this policy, fundus photography to guide a given treatment or intervention (vs. monitoring for progression) e.g., photos used to guide the placement of macular laser treatment or to monitor the response to intraocular vascular endothelial growth factor (VEGF) agents should only be ordered by the physician who actually performs the treatment or intervention. Extended ophthalmoscopy An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions (THIS LIST MAY NOT BE EXHAUSTIVE): a. Malignant neoplasm of the retina or choroid b. Retained (old) intraocular foreign body, either magnetic or nonmagnetic c. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration d. Retinal detachment with or without retinal defect-the patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as “a curtain came down over my eyes.” e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters) f. Retinal defects without retinal detachment g. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers-this may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation h. Sudden visual loss or transient visual loss i. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment j. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye k. Blunt injury to the eye or adnexa l. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment)-spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders m. Posterior scleritis-signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field n. Vogt-Koyanagi-Harada syndrome- A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea o. Degenerative disorders of the globe p. Retinoschisis and retinal cysts-patients may complain of light flashes and floaters q. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision r. Glaucoma or is a glaucoma suspect-this may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve s. Systemic disorders which may be associated with retinal pathology t. High axial length myopia u. Retinal edema v. Metamorphopsia w. High-risk medication for retinopathy or optic neuropathy x. Choroidal nevus being evaluated for malignant transformation y. Macular degeneration 3. Limitations: If the study is performed as a screening service, it is not covered by Medicare. Fundus photography All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary. Fundus photography of a normal retina will be denied as not medically necessary. Extended ophthalmoscopy Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary.