0734 external ocular photography - aetnabetterhealth.com · pseudopterygium pterygium, unspecified,...

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Last Review 02/09/2018 Effective: 08/10/2007 Next Review: 08/09/2018

Review History

Definitions

Clinical Policy Bulletin Notes

Number: 0734

Policy *Pleasesee amendment forPennsylvaniaMedicaidattheendofthis CPB.

Aetna considers external ocular photography medically necessary for the following indications to track and serially compare the changes of the condition, where the results may have an impact on management and clinical outcomes:

Acid chemical burn of cornea and conjunctival sac Acute inflammation of orbit, unspecified Adherent leucoma Adhesions of iris, unspecified Alkaline chemical burn of cornea and conjunctival sac Anterior dislocation of lens Anterior pigmentation Anterior synechiae Argentous deposits Band‐ shaped keratopathy Benign neoplasm of conjunctiva Benign neoplasm of cornea Benign neoplasm of eye, part unspecified Benign neoplasm of eyeball, except retina and choroid Benign neoplasm of eyelid, including canthus

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Benign neoplasm of lacrimal duct Benign neoplasm of lacrimal gland Benign neoplasm of orbit Benign neoplasm of other s pecified parts of eye Benign neoplasm of skin of other and unspecified parts of

face Blisters, with epidermal loss due to burn (second degree) of

eye (with other parts of face, head, and neck) Bullous keratopathy Burn of unspecified degree of eye (with other parts of face,

head, and neck) Burn with resulting rupture and destruction of eyeball Carcinoma in situ of eye Carcinoma of eyelid, including canthus Central corneal ulcer Central opacity of cornea Chemical burn of eyelids and periocular area Congenital ptosis Conjunctival melanosis Constant exophthalmos Corneal abscess Corneal deformity, unspecified Corneal degeneration, unspecified Corneal deposit, unspecified Corneal dystrophy, unspecified Corneal ectasia Corneal edema due to wearing of contact Corneal edema, unspecified Corneal membrane change, unspecified Corneal neovascularization, unspecified Corneal opacity, unspecified Corneal staphyloma Corneal ulcer, unspecified Deep necrosis of underlying tissues due to burn (deep third

degree) of eye (with other parts of face, head, and neck), without mention of loss of body part

Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), with loss of a body part

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External Ocular Photography - Medical Clinical Policy Bulletins | Aetna http://qawww.aetna.com/cpb/medical/data/700_799/0734_tempdraft.html

Deep vascularization of cornea Degeneration of pupillary margin Degenerative changes of chamber angle Degenerative changes of ciliary body Dermatochalasis of upper eyelids Descematocele Diffuse interstitial keratitis Double pterygium, to follow in lieu of surgery Endothelial corneal dystrophy Erythema due to burn (first degree) of eye (with other parts

face, head, and neck) Essential or progressive iris atrophy Exophthalmic ophthalmoplegia Exophthalmos, unspecified Exudative cysts of iris or anterior chamber Folds and rupture of Bowman's membrane Folds in Descemet's membrane Full‐thickness skin loss due to burn (third degree NOS) of eye

(with other parts of face, head, and neck) Goniosynechiae Granular corneal dystrophy Herpes simplex disciform keratitis Herpes zoster keratoconjunctivitis Hyphema Hypopyon Hypopyon ulcer Idiopathic corneal edema Idiopathic cysts Implantation cysts Interstitial keratitis, unspecified Iridoschisis Juvenile epithelial corneal dystrophy Kayser‐Fleischer ring Keratoconus, acute hydrops Keratoconus, stable condition Keratoconus, unspecified Keratomalacia NOS Late effect of other and unspecified external causes Lattice corneal dystrophy

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Limbal and corneal involvement in vernal conjunctivitis Localized adhesions and strands of conjunctiva Localized vascularization of cornea Macular corneal dystrophy Malignant neoplasm of conjunctiva, unless excision is

planned Malignant neoplasm of the cornea, unless excision is

planned Marginal corneal ulcer Minor opacity of cornea Miotic cysts of pupillary margin Mooren's ulcer Mycotic corneal ulcer Neurotrophic keratoconjunctivitis Nodular degeneration of cornea Orbital cellulitis Other and unspecified superficial injuries of eye Other anterior corneal dystrophies Other burn of cornea and conjunctival sac Other burns of eyelids and periocular area Other calcareous degeneration of cornea Other corneal degenerations Other deposits associated with metabolic disorders Other disorders of iris and ciliary body Other forms of keratitis Other posterior corneal dystrophies Other stromal corneal dystrophies Pannus (corneal) Perforated corneal ulcer Peripheral degenerations of cornea Peripheral opacity of cornea Peripheral pterygium, progressive, to follow in lieu of

surgery Phacolytic glaucoma Phlyctenular keratoconjunctivitis Pigmentary iris degeneration Posterior dislocation of lens Posterior pigmentations Posterior synechiae

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Pseudopterygium Pterygium, unspecified, to follow in lieu of surgery Ptosis of eyelid Pupillary abnormalities Pupillary membranes Recession of chamber angle Recurrent erosion of cornea Recurrent pterygium, to follow in lieu of surgery Ring corneal ulcer Rubeosis iridis Rupture in Descemet's membrane Scleral melanosis Sclerosing keratitis Secondary corneal edema Stromal pigmentations Subluxation of lens Superficial injury of conjunctiva Superficial injury of cornea Superficial injury of eyelids and periocular area Symblepharon Thyrotoxic exophthalmos Unspecified burn of eye and adnexa Unspecified corneal disorder Unspecified disorder of iris and ciliary body Unspecified keratitis Vascular anomalies of eyelid.

External ocular photography has no proven value for other indications (e.g., epiblepharon with trichiasis, evaluating conjunctival hemorrhage, keratoconjunctivitis sicca, and monitoring pinguecula).

Aetna considers external ocular photography not medically necessary for the sole purpose of documenting the existence of an ocular condition in order to enhance the medical record.

Background External ocular photography can be used to document the

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progress or deterioration of certain conditions of the external structures of the eye including the eyelids, lashes, sclerae, conjunctiva and cornea. It may also be used to document progress and deterioration of structures of the anterior chamber including the iris, and filtration angle. These photographs are commonly made using slit lamp photography, goniophotography, stereophotography or close‐up photography. Regardless of the technique used for the picture taking, the pictures may be stored as prints, slides, videotape or digital medium.

External ocular photography is clinically useful for tracking slowly progressive conditions over prolonged periods of time, where it may be impractical to document progression with hand drawings due to the need to document fine detail, especially where there is a lack of anatomic landmarks.

Epiblepharon with Trichiasis:

An UpToDate review on “Approach to the child with persistent tearing” (Paysse et al, 2016) states that “Eyelid abnormalities ‐Anatomic abnormalities of the eyelids may cause tearing, redness, and foreign body sensation. Trichiasis (ingrown eyelashes) can irritate the cornea, causing reflex tearing and redness, and may be caused by entropion or epiblepharon. Entropion is the in‐turning of the eyelid; epiblepharon is a fold of skin along the lower lid margin, just below the eyelashes. Both of these conditions can be associated with trichiasis. Entropion, if significant, is treated with surgical repair. Children usually outgrow epiblepharon by 2 to 3 years of age without needing to undergo surgery”. This review does not mention external ocular photography as a management tool.

Keratoconjunctivitis Sicca:

Rutar et al (2015) determined the ophthalmic manifestations of HIV in a cohort of long‐term survivors of perinatally acquired HIV. A total of 22 patients with perinatally acquired HIV who were aged greater than or equal to 12 years were prospectively

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studied at a university clinic. They underwent complete ophthalmic examinations and fundus photography. Their medical histories, medications and CD4 counts were abstracted from the medical records. To evaluate for kerato‐conjunctivitis sicca (KCS), both HIV patients and 44 healthy controls (matched by age, gender and contact lens wear) underwent Schirmer testing and ocular surface staining; 9 male and 13 female HIV patients with mean age of 16.6 years (SD, 3.4) were examined. Of the 22 HIV patients, 21 had been treated with highly active anti‐retroviral therapy (HAART). Only 1 patient had a CD4 count nadir of less than 200 cells/µL. The mean visual acuity (VA) of the eyes of the HIV subjects was 20/22 (SD, 1.6 lines). No patient had cytomegalovirus retinitis; 4 of the 22 (18 %) HIV patients had strabismus. HIV subjects and controls had similar rates of abnormal Schirmer (9 % and 14 %, p = 0.62) and ocular staining scores (p = 0.29). The authors concluded that in the post‐HAART era, long‐term survivors of perinatally acquired HIV exhibited little vision‐threatening disease, but had a high prevalence of strabismus.

Safonova et al (2016) noted that laser confocal tomography of the cornea enables studying ultrathin sections of corneal layers, which provides additional reliable information on tissue changes in KCS. These researchers evaluated the significance of laser confocal tomography of the cornea in the diagnosis and monitoring of KCS. They investigated 38 eyes of 30 patients with severe KCS. The patients were divided into 2 groups: Group 1 (15 patients, 19 eyes) was prescribed cyclosporine А 1.5 % instillations 2 times daily, artificial tears, and soft contact lenses, and Group 2 (15 patients, 19 eyes) received only instillations of cyclosporine А 0.05% 2 times daily and artificial tears. Besides standard ophthalmic examination, additional tests were performed, namely Schirmer's test, tear break‐up time test, fluorescein eye stain test, tear osmolarity test (TearLab System, USA), and Heidelberg retinal tomography of the cornea (HRT, Heidelberg Engineering GmbH, Germany). HRT findings revealed a 3 times shorter epithelization period and faster recovery of corneal transparency in Group 1 as compared to Group 2 (1.5 and 4.5 months, respectively). There

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was also an evident reduction in the number of immune cells in the cornea, most pronounced in group 1 at 3 months, which was indicative of inflammation termination. The authors concluded that the use of HRT of the cornea in KCS patients allowed real‐time cellular level observation of corneal changes, which together with clinical findings and diagnostic tests not only confirmed the diagnosis but also determined treatment effectiveness. It has been also found that soft contact lenses accelerated epithelization of the cornea and relieved inflammation of the ocular surface in KCS patients under cyclosporine A 0.05 % instillation therapy.

An UpToDate review on “Diagnosis and classification of Sjögren's syndrome” (Baer , 2017a) states that “KCS is characterized primarily by a deficiency in tear production, while hypovitaminosis A is characterized by disordered conjunctival and corneal epithelial turnover, leading to keratinization and a loss of conjunctival goblet cells, resulting in tear mucin deficiency”; it does not mention ocular photography as a management tool.

An UpToDate review on “Clinical manifestations of Sjögren's syndrome: Exocrine gland disease” (Baer, 2017b) does not mention ocular photography as a management tool.

Furthermore, an American Academy of Ophthalmology’s guideline on “Dry eye syndrome” (AAO, 2013) had no recommendation for external ocular photography, either for diagnosis or follow‐up.

CPT Codes / HCPCS Codes / ICD‐10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes covered if selection criteria are met:

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92285 External ocular photography with interpretation and report for documentation of medical progress (e.g., close‐up photography, slit lamp photography, goniophotography, stereo‐ photography)

ICD‐10 codes covered if selection criteria are met:

B00.52 Herpes viral keratitis

B02.33 Zoster keratitis

C44.101 ‐ C44.199

Other and unspecified malignant neoplasm of eyelid, including canthus

C44.101 -

C69.00 -C69.02

Malignant neoplasm of conjunctiva

C69.10 -C69.12

Malignant neoplasm of cornea

D04.10 -D04.12

Carcinoma in situ of skin of eyelid, including canthus

D09.20 -D09.22

Carcinoma in situ of eye

D23.10 -D23.12

Other benign neoplasm of skin of eyelid, including canthus

D23.30 -D23.39

Other benign neoplasm of skin of other and unspecified parts of face

D31.00 -D31.02

Benign neoplasm of conjunctiva

D31.10 -D31.12

Benign neoplasm of cornea

D31.40 -D31.42

Benign neoplasm of ciliary body

D31.50 -D31.52

Benign neoplasm of lacrimal gland and duct

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D31.60 -D31.62

Benign neoplasm of unspecified site of orbit

D31.90 -D31.92

Benign neoplasm of unspecified part of eye

H02.401 ‐ H02.439

Ptosis of eye

H02.871 -H02.879

Vascular anomalies of eyelid

H05.00 Unspecified acute inflammation of orbit

H05.011 ‐ H05.019

Cellulitis of orbit

H05.20 Unspecified exophthalmos

H05.241 -H05.249

Constant exophthalmos

H05.89 Other disorders of orbit [thyrotoxic exophthalmos, exophthalmic ophthalmoplegia]

H11.001 -H11.019

Unspecified and amyloid pterygium of eye

H11.031 -H11.039

Double pterygium of eye

H11.051 -H11.059

Peripheral pterygium of eye, progressive

H11.061 -H11.069

Recurrent pterygium of eye

H11.131 ‐H11.139

Conjunctival pigmentations [melanosis]

H11.211 ‐H11.219

Conjunctival adhesions and strands (localized)

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H11.231 ‐ H11.239

Symblepharon

H11.811 ‐ H11.819

Pseudopterygium of conjunctiva

H15.89 Other disorders of sclera [melanosis]

H16.001 -H16.079

Corneal ulcer

H16.231 ‐ H16.239

Neurotrophic keratoconjunctivitis

H16.251 ‐ H16.259

Phlyctenular keratoconjunctivitis

H16.261 -H16.269

Vernal keratoconjunctivitis, with limbal and corneal involvement

H16.301 -H16.309

Unspecified interstitial keratitis

H16.311 -H16.319

Corneal abscess

H16.321 -H16.329

Diffuse interstitial keratitis

H16.331 ‐ H16.339

Sclerosing keratitis

H16.401 -H16.409

Unspecified corneal neovascularization

H16.421 ‐ H16.429

Pannus (corneal)

H16.431 -H16.439

Localized vascularization of cornea

H16.441 -H16.449

Deep vascularization of cornea

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H16.8 Other keratitis

H16.9 Unspecified keratitis

H17.00 -H17.9

Corneal scars and opacities

H18.001 -H18.069

Corneal pigmentations and deposits

H18.10 ‐H18.13

Bullous keratopathy

H18.20 -H18.239

Other and unspecified corneal edema

H18.30 -H18.339

Changes of corneal membranes

H18.40 Unspecified corneal degeneration

H18.421 -H18.429

Band keratopathy

H18.43 Other calcerous degeneration of cornea

H18.441 ‐H18.449

Keratomalacia

H18.451 -H18.459

Nodular corneal degeneration

H18.461 -H18.469

Peripheral corneal degeneration

H18.49 Other corneal degeneration

H18.50 -H18.59

Hereditary corneal dystrophies

H18.601 ‐H18.629

Keratoconus

H18.70 -H18.799

Other and unspecified corneal deformities

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H18.831 -H18.839

Recurrent erosion of cornea

H18.9 Unspecified disorder of cornea

H20.051 ‐H20.059

Hypopyon

H21.00 -H21.279 H21.301 -H21.329 H21.40 -H21.529 H21.541 -H21.569 H21.81, H21.89 -H21.9

Other disorders of iris and ciliary body

H27.10 -H27.139

Dislocation of lens

H40.50x0 -H40.53x4

Glaucoma secondary to other eye disorders [Phacolytic glaucoma]

Q10.0 Congenital ptosis

S00.201+ -S00.279+

Other and unspecified superficial injuries of eyelid and periocular area

S05.00x+ -S05.02x+

Injury of conjunctiva and corneal abrasion without foreign body

S05.90x+ -S05.92x+

Unspecified injury of eye and orbit

T26.00x+ -T26.92x+

Burns and corrosion confined to eye and adnexa

ICD‐10 codes not covered for indications listed in the CPB (not all‐inclusive):

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H02.051 ‐H02.059

Trichiasis without entropian

H11.151 ‐H11.159

Pinguecula

H11.30 ‐H11.33

Conjunctival hemorrhage

H16.221 ‐H16.229

Keratoconjunctivitis sicca, not specified as Sjögren's

Q10.3 Other congenital malformations of eyelid [epiblepharon]

The above policy is based on the followingreferences:

1. Saine PJ. Tutorial: External ocular photography. J Ophthalmic Photography. 2006;28(1):8‐20.

2. HealthNow UMD. Ocular photography, external. Contractor's Determination No. OP016E00. February 20, 2006.

3. Farrow A. Clinical ocular photography. Br J Ophthalmol. 2000;84(8):363G.

4. Fogla R, Rao SK. Ophthalmic photography using a digital camera. Indian J Ophthalmol. 2003;51(3):269‐272.

5. Paysse EA, Coats DK, Cassidy M. Approach to the child with persistent tearing. UpToDate Inc., Waltham, MA. Last reviewed June 2016.

6. Rutar T, Youm J, Porco T, et al. Ophthalmic manifestations of perinatally acquired HIV in a US cohort of long‐term survivors. Br J Ophthalmol. 2015;99(5):650‐653.

7. Safonova TN, Gladkova OV, Boev VI. Significance of laser confocal tomography in diagnosis and monitoring of keratoconjunctivitis sicca. Vestn Oftalmol. 2016;132(2):47‐54.

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8. Baer AN. Diagnosis and classification of Sjögren's syndrome. UpToDate Inc., Waltham, MA. Last reviewed May 2017a.

9. Baer AN. Clinical manifestations of Sjögren's syndrome: Exocrine gland disease. UpToDate Inc., Waltham, MA. Last reviewed May 2017b.

10. American Academy of Ophthalmology (AAO). Dry dye syndrome. Preferred Practice Pattern. San Francisco, CA: AAO; October 2013.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0734 External Ocular

Photography

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 02/09/2018

http://www.aetnabetterhealth.com/pennsylvania

0734 external ocular photography - aetnabetterhealth.com · pseudopterygium pterygium, unspecified,...

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