92225_R10

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.

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions:

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

Limitations

If the study is performed as a screening service, it is not covered by Medicare.

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.