Latest Review: May 2024

Category: Vision

POLICY:

Ocular photoscreening, when performed in the primary care physician’s office as a screening tool to detect amblyogenic factors, is considered investigational.

*Also refer to medical policy #447: Preventive Care Services Under Healthcare Reform for additional information. For health care reform compliant plans, mandated provision of services may apply.

DESCRIPTION OF PROCEDURE OR SERVICE:

Many children permanently lose vision each year as a result of amblyopia, media opacities, and treatable ocular disease processes. Early diagnosis and treatment of these conditions has been shown to yield better visual outcomes. Amblyopia is the most common cause of visual impairment among children. Unless it is successfully treated in early childhood, amblyopia usually persists into adulthood. It is also the most common cause of monocular (one eye) visual impairment among young and middle-aged adults.

Ocular photoscreening has been investigated as an alternative screening method to detect risk factors for amblyopia, which include strabismus, high refractive errors, anisometropia, and media opacities. Ocular photoscreening is based on the principle of photo refraction in which the refractive state of the eye is assessed via the pattern of light reflected through the pupil. The images can then be analyzed based on the position of the corneal light reflex as well as the overall reflection of light from the fundus, which provides information on the child’s fixation pattern and the presence or absence of strabismus. Patients are photographed in a darkened room while looking at the camera. The photographs can be sent to a central laboratory for analysis, either by ophthalmologists or specifically trained personnel. Results are typically graded as pass, fail or repeat photoscreening.

An advantage of ocular photoscreening over standard methods of testing visual acuity (i.e. use of Snellen charts, letters, etc.) is that photoscreening requires little cooperation from the child, other than having to fixate on the appropriate target long enough for photoscreening. Thus, photoscreening has the potential to improve vision screening rates in preverbal children and those with developmental delays who are the most difficult to screen. Many of the children that are most difficult to screen using conventional methods are also at highest risk of amblyopia (e.g., premature infants, children with developmental delays).

Ocular photoscreening can be performed in several settings. For example, photoscreening can be performed in public health setting or as part of school screening programs. In addition, photoscreening may be performed by ophthalmologists as an adjunct to an ophthalmologic exam.

*Note: This policy addresses the use of photoscreening in the primary care physician office setting, where it is performed as an adjunct or alternative to the standard visual exam. It is anticipated that the results of photoscreening would be used by the primary care physician to determine whether the patient required referral to a pediatric ophthalmologist for further evaluation.

KEY POINTS:

This policy has been updated with review of literature performed through May 10, 2024.

Summary of Evidence

No studies have been identified that evaluate whether the results of ocular photoscreening performed in the primary care physician office setting leads to higher referral rates to ophthalmologists, earlier diagnosis and treatment, or a decrease in vision-impairing amblyopia, when compared to a standard visual assessment. Randomized controlled trials and/or other well-designed scientific evidence proving this technology, when used in the primary care physician office setting, results in improved outcomes is needed. The evidence is insufficient to determine that the use of ocular photoscreening in the primary care physician’s office improves overall net health outcomes.

Practice Guidelines and Position Statements

American Academy of Ophthalmology (AAO)

The American Academy of Ophthalmology (AAO) Preferred Practice Patterns for Pediatric Eye Evaluations (2022) state that vision screening should be performed at an early age and at regular intervals throughout childhood. The elements of vision screening vary depending on the age and level of cooperation of the child. Subjective visual acuity testing is preferred to instrument-based screening in children who are able to participate reliably. Instrument-based screening is useful for some young children and those with developmental delays. Instrument-based screening techniques, such as photoscreening and auto refraction, are useful for assessing amblyopia and reduced-vision risk factors for children ages one to five years, as this is a critical time for visual development. Instrument-based screening can occur for children at age six years and older when children cannot participate in optotype-based screening.

American Academy of Pediatrics (AAP)

The AAP presented the following policy statement in 2012:

Photoscreening and handheld auto refraction may be electively performed in children six months to three years of age, allowing earlier detection of conditions that may lead to amblyopia, as well as in older children who are unable or unwilling to cooperate with routine acuity screening. Photoscreening and handheld auto refraction are recommended as an alternative to visual acuity screening with vision charts from three through five years of age. The use of vision charts and standard physical examination techniques to assess amblyopia in children three to five years of age in the medical home remains a viable practice at the present time. There is no recommendation for mass screening at this time.

U.S. Preventive Services Task Force Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends vision screening for all children at least once between the ages of three and five years, to detect the presence of amblyopia or its risk factors.

Various screening tests that are feasible in primary care are used to identify visual impairment among children. These tests include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of auto refractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors).

KEY WORDS:

Ocular photoscreening, MTI PhotoScreener, photoscreening, ocular, iScreen, iScreen Vision Screener

APPROVED BY GOVERNING BODIES:

Examples of U.S. Food and Drug Administration (FDA) approved photoscreeners available:

• Those in which the screener interprets the photograph (such as MTI Photoscreener™, Medical Technology and Innovations, Inc., Lancaster, PA; Visiscreen 100™, Vision Research Corporation, Birmingham, AL)
• Those in which a computer interprets the photograph (such as The EyeDx System™, EyeDx, Inc., San Diego, CA).

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.  

CURRENT CODING:

CPT Codes:

REFERENCES:

1. Arnold RW, et al. performance of four new photoscreeners on pediatric patients with high risk amblyopia. J Pediatr Ophthalmol Strabismus 2014 Jan-Feb; 51(1):46-52.
2. Committee on Practice and Ambulatory Medicine Section on Ophthalmology; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians: organizational principles to guide and define the child health care system and/or improve the health of all children. Ophthalmology. 2003 Apr; 110(4):860-5.
3. Donahue S, Baker C. Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2016; 137; 1.
4. Garry GA, et al. Validation of Spot screening device for amblyopia risk factors. JAAPOS 2014 Oct; 18(5):476-80.
5. Halegoua J, et al. Vision photoscreening of infants and young children in a primary care pediatric office: can it identify asymptomatic treatable amblyopic risk factors? Clin Pediatr 2015 Jan; 54(1):33-9.
6. Kemper AR, Clark SJ. Preschool vision screening in pediatric practices. Clin Pediatr (Phila). 2006 Apr; 45(3):263-6.
7. Kulp MT, Vision in Preschoolers Study Group. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci 2009; 86: 619-623.
8. Laiginhas, R., Ferreira, C. C., Leitão, R., Geraldes, R., Chibante-Pedro, J., Monteiro, M., & de Matos, C. (2020). Prevalence of Amblyopia After Photoscreening. Journal of pediatric ophthalmology and strabismus, 57(6), 372–377. doi.org/10.3928/01913913-20200824-01Loh AR, Chiang MF. Pediatric Vision Screening. Pediatr Rev. 2018 May; 39(5):225-234.
9. Longmuir SQ, Pfeifer W, Leon A et al. Nine-year results of a volunteer lay network photoscreening program of 147,809 children using a photoscreener in Iowa. Ophthalmology 2010; 117(10):1869-75.
10. Lowry EA, Wang W, Nyong'o O. Objective vision screening in 3-year-old children at a multispecialty practice. J AAPOS. 2015 Feb; 19(1):16-20.
11. McConaghy, J. R., & McGuirk, R. (2019). Amblyopia: Detection and Treatment. American family physician, 100(12), 745–750.
12. Miller JM, Lessin HR; American Academy of Pediatrics Section on Ophthalmology; Committee on Practice and Ambulatory Medicine; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Instrument-based pediatric vision screening policy statement. Pediatrics. 2012 Nov; 130(5):983-6. 
13. Peterseim MM, et al. Photoscreeners in the pediatric eye office: compared testability and refractions on high-risk children. Am J Ophthalmol 2014 Nov; 158(5):932-8.
14. Ransbarger KM, et al. Results of a community vision-screening program using the Spot photoscreener. J AAPOS 2013 Oct; 17(5):516-20.
15. U.S. Preventive Services Task Force (USPSTF). Final Recommendation Statement: Visual Impairment in Children Ages 6 months to 5 years: Screening. U.S. Preventive Services Task Force. September 2018.
16. Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA, Christiansen SP; American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern®: I. Vision Screening in the Primary Care and Community Setting; II. Comprehensive Ophthalmic Examination. Ophthalmology. 2018 Jan; 125(1):P184-P227.
17. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.

POLICY HISTORY:

Medical Policy Group, June 2004 (3)

Medical Policy Administration Committee, September 2004

Available for comment September 7-October 21, 2004

Medical Policy Group, June 2006 (1)

Medical Policy Group, June 2008 (1)

Medical Policy Group, June 2010 (1): Key Points updated, policy statement remain unchanged

Medical Policy Group, December 2010 (1): Key Points updated, reference list updated

Medical Policy Group, December 2012 (3): 2013 Coding Updates: Verbiage change to Code 99174 (effective 01/01/2013)

Medical Policy Group, December 2012 (3): Effective 12/26/2012 - Active policy but no longer scheduled for regular literature reviews and update.

Medical Policy Group, October 2013 (1): Removed ICD-9 Diagnosis codes; no change to policy statement.

Medical Policy Group, July 2015 (3): editing update only; added under the policy section a reference to medical policy #447 Preventive Care Services under Healthcare Reform; no change in policy intent; except when mandated, service still considered investigational

Medical Policy Group, November 2015: 2016 Annual Coding Update. Added CPT code 99177 to current coding. Revised CPT code 99174.

Medical Policy Group, September 2016 (3): Literature review with updates to Description, Key Points, Key Words, & References; no change in policy statement.

Medical Policy Group, August 2019 (6): Updates to Description and Key Points. No change to policy intent.

Medical Policy Group, March 2021 (9): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Updates to Description, Key Points. Policy statement updated to remove “not medically necessary,” no change to policy intent.

Medical Policy Group, April 2022 (9): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Updates to Description, Key Points. Punctuation added for clarity to policy statement. No change to policy intent.

Medical Policy Group, April 2023 (9): Reviewed by consensus. Updates to Key Points, Benefit Application and References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, May 2024 (5): Reviewed by consensus. Updates to Key Points and References. No change to Policy Statement. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.