P07.18 — Other low birth weight newborn, 2000-2499 grams
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Images must be obtained (digital fundus photographs) by trained personnel (e.g., trained photographer/technician) and electronically transmitted to a reading center for evaluation (described throughout background and device descriptions).
- Remote clinical staff review and report (for CPT 92227) or remote physician/other qualified health care professional interpretation and report (for CPT 92228) must be documented (implied by CPT descriptors used in the CPB).
- Documentation of image adequacy and, if images are inadequate to allow assessment, documentation that the patient was referred for further evaluation by an ophthalmologist or optometrist (Inoveon recommendation described in policy).
- Evidence of grading/evaluation workflow: readings by trained non-physician technicians, rereading of a selected sample for inter- and intra-rater reliability, and secondary ophthalmologist review of questionable/pathologic images (quality assurance protocols referenced; policy notes QA should meet or exceed HEDIS specifications).
Key Coverage Criteria
- Screening diabetic retinopathy as an alternative to retinopathy screening by an ophthalmologist or optometrist (medical necessity per policy).
- Screening retinopathy of prematurity as an alternative to retinopathy screening by an ophthalmologist or optometrist (medical necessity per policy).
- CPT codes covered if selection criteria are met: 92227 (Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report, unilateral or bilateral) and 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).
- HCPCS code related: S3000 (Diabetic indicator; retinal eye exam, dilated, bilateral) (listed as related to the CPB).
- ICD-10 codes covered if selection criteria are met (Diabetes except with ophthalmic manifestations): E10.10 - E10.29; E10.40 - E10.9; E11.00 - E11.29; E11.40 - E11.9; E13.00 - E13.29; E13.40 - E13.9.
- ICD-10 codes listed for retinopathy of prematurity: H35.101 - H35.179.
4 Active Policies
AMBETTER-CP.VP.26 — Extended Ophthalmoscopy
AETNA-CPB-0563 — Retinopathy Telescreening Systems
AETNA-CPB-0579 — T-Wave Alternans
ANTHEM-CG-LAB-25 — CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
Related Codes
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