Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    QualChoice considers diabetic retinopathy tele screening systems medically necessary for diabetic retinopathy screening as an alternative to retinopathy screening by an ophthalmologist or optometrist.

2)    QualChoice considers tele screening systems experimental and investigational for any other indications because of insufficient evidence of their clinical value for these indications (not an all-inclusive list):

a)    Following the progression of disease in members who are diagnosed with diabetic retinopathy;

b)    Screening or evaluating retinal conditions other than diabetic retinopathy, including, but not limited to macular degeneration/edema;

c)    Screening for retinopathy of prematurity. 

1)    Remote imaging for detection of retinal disease is covered once every 12 months, without prior authorization for members with:

a)    Type I diabetes OR Type II diabetes AND

b)    No history of diabetic retinopathy or any other type of retinal disease AND

c)    The imaging technique is performed with a U.S. Food and Drug Administration (FDA) approved device for retinal tele screening; AND

d)    The final images are graded for diabetic retinopathy using a manual process by an Ophthalmologist.

2)    Remote imaging for monitoring and management of any active retinal disease, including diabetic retinopathy, is not covered.

Codes Used In This BI:

92227       Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report, unilateral or bilateral (code revised eff 01-01-2021)

92228       Imaging of retina for detection or monitoring of disease; with remote physician or other qualified health care professional interpretation and report, unilateral or bilateral (code revised eff 01-01-2021)

1.    Bragge P, Gruen RL, Chau M, et al. screening for presence or absence of diabetic retinopathy: a meta-analysis. Arch Ophthalmol. 2011; 129(4):435-444.

2.    Farley TF, Mandava N, Prall FR, Carsky C. Accuracy of primary care clinicians in screening for diabetic retinopathy using single-image retinal photography. Ann Fam Med. 2008; 6(5):428-434.

3.    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.

4.    Ku JJ, Landers J, Henderson T, Craig JE. The reliability of single-field fundus photography in screening for diabetic retinopathy: the Central Australian Ocular Health Study. Med J Aust. 2013; 198(2):93-96.

5.    Lim JI, Labree L, Nichols T, et al. Comparison of nonmydriatic digitized video fundus images with standard 35-mm slides to screen for and identify specific lesions of age-related macular degeneration. Retina. 2002; 22(1):59-64.

6.    Mansberger SL, Sheppler C, Barker G, et al. Long-term comparative effectiveness of telemedicine in providing diabetic retinopathy screening examinations: a randomized clinical trial. JAMA Ophthalmol. 2015; 133(5):518-525.

7.    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):920-924.

8.    Osareh A, Mirmehdi M, Thomas B, et al. Automated identification of diabetic retinal exudates in digital color images. Br J Ophthalmol. 2003; 87(10):1220-1223.

9.    Rudnisky CJ, Hinz BJ, Tennant MTS, et al. High-resolution stereoscopic digital fundus photography versus contact lens bio microscopy for the detection of clinically significant macular edema. Ophthalmology. 2002; 109(2):267-274.

10.   Saari JM, Summanen P, Kivela T, Saari KM. Sensitivity and specificity of digital retinal images in grading diabetic retinopathy. Acta Ophthalmol Scand. 2004; 82(2):126-130.

11.   Shi L, Wu H, Dong J, et al. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol. 2015; 99(6):823-831.

12.   Tu KL, Palimar P, Sen S, et al. Comparison of optometry vs. digital photography screening for diabetic retinopathy in a single district. Eye (Lond). 2004; 18(1):3-8.

13.   Van Leeuwen R, Chakravarthy U, Vingerling JR, et al. Grading of age-related maculopathy for epidemiological studies: is digital imaging as good as 35-mm film? Ophthalmology. 2003; 110(8):1540-1544.

14.   Whited JD. Accuracy and reliability of tele ophthalmology for diagnosing diabetic retinopathy and macular edema: a review of the literature. Diabetes Technol Ther. 2006; 8(1):102-111.

15.   Zimmer-Galler I, Zeimer R. Results of implementation of the Digi Scope for diabetic retinopathy assessment in the primary care environment. Telemed J E Health. 2006; 12(2):89-98. American Academy of Ophthalmology (AAO). Clinical Statement. Screening for diabetic retinopathy (2014). For additional information visit the AAO website: http://www.aao.org/. Accessed on January 9, 2017.

16.   American Academy of Ophthalmology (AAO). Preferred Practice Pattern®. Diabetic Retinopathy. 2016. For additional information visit the AAO website: http://www.aao.org/. Accessed on January 9, 2017.

17.   American Academy of Ophthalmology (AAO). Ophthalmic Technology Assessment. Single-field fundus photography for diabetic retinopathy screening. 2004; 111(5):1055-1062.

18.   American Diabetes Association. Standards of medical care in diabetes--2017. Diabetes Care. 2017; 40 Suppl 1:S1-S135. Available at:  http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf. Accessed on January 9, 2017.

19.   Fong DS, Aiello L, Gardner TW, et al. American Diabetes Association position statement: retinopathy in diabetes. Diabetes Care. 2004; 27(Suppl 1):S84-S87.

20.   U.S. Food and Drug Administration 510(k) Premarket Notification Database. Digi scope ophthalmic camera. Summary of Safety and Effectiveness. No. K990205. Rockville, MD: FDA. March 26, 1999. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/k990205.pdf. Accessed on January 9, 2017.

21.   National Eye Institute. U.S. National Institutes of Health. Facts about diabetic eye disease. Last updated September 2015. Available at: https://www.nei.nih.gov/health/diabetic . Accessed on January 9, 2017

Addendum:

1)    Effective 01/01/2019: Diabetic tele-retinal eye exam are covered once every year under preventive benefit for diabetics without any known eye complications.

2)    Effective 01/01/2021: Updated codes 92227 and 92228.