M-82-005

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

M-82-005

Topic:

Electroretinography

Section:

Diagnostic Medical

Effective Date:

October 1, 2023

Issued Date:

October 1, 2023

Last Revision Date:

September 2023

Annual Review:

June 2023

Full field electroretinogram (ERG) is used to detect loss of retinal function or distinguish between retinal and optic nerve lesions. ERG measures the electrical activity generated by neural and non-neuronal cells in the retina in response to a light stimulus.

Focal or foveal electroretinogram (fERG) is useful in providing information regarding diseases limited to the macula.

Multi-focal electroretinography (mfERG) is a higher resolution form of ERG, enabling assessment of ERG activity in small areas of the retina.

Pattern electroretinogram (PERG) uses pattern-reversal stimuli and is used to detect subtle optic neuropathies.

Policy Position

Electroretinography used to diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions may be considered medically necessary for ANY ONE of the following indications (This is not an all-inclusive list):

Toxic retinopathies, including those caused by intraocular metallic foreign bodies, Vigabatrin and Chlorpromazine; or
Diabetic retinopathy; or
Retinal vascular disease (e.g., Central Retinal Artery Occlusion [CRAO], Transient Retinal Artery Occlusion, Central Retinal Vein Occlusion [CRVO], Branch Vein Occlusion [BVO], and sickle cell retinopathy) ; or
Autoimmune retinopathies (e.g., Cancer Associated Retinopathy [CAR], Melanoma Associated Retinopathy [MAR], and Acute Zonal Occult Outer Retinopathy [AZOOR]) ; or
Retinal detachment; or
Assessment of retinal function after trauma (e.g., vitreous hemorrhage, dense cataracts, macula scars and other conditions where the fundus cannot be visualized) ; or
Retinitis pigmentosa and related hereditary degenerations; or
Retinitis punctata albescens; or
Leber's congenital amaurosis; or
Choroideremia; or
Gyrate atrophy of the retina and choroid; or
Goldman-Favre syndrome; or
Congenital stationary night blindness; or
X-linked juvenile retinoschisis; or
Achromatopsia; or
Cone dystrophy; or
Disorders mimicking retinitis pigmentosa; or
Usher Syndrome; or
Retinal Dystrophies (e.g., Stargardt’s disease, Fundus Flavimaculata, North Carolina macular dystrophy, Best’s Vitelliform dystrophy, Sorsby’s macular dystrophy).

mfERG may be considered medically necessary to detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity.

Electroretinography not meeting the criteria as indicated in this policy, is considered not medically necessary.

0509T

92273

92274

ALL forms of electroretinography (ERG, fERG, mfERG, and PERG) for either diagnosis or management of glaucoma are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

0509T

92273

92274

Covered Diagnosis Codes for procedure codes 0509T, 92273, and 92274

A18.53	D18.09	E08.311	E08.319	E08.3211	E08.3212	E08.3213
E08.3291	E08.3292	E08.3293	E08.3311	E08.3312	E08.3313	E08.3391
E08.3392	E08.3393	E08.3411	E08.3412	E08.3413	E08.3491	E08.3492
E08.3493	E08.3511	E08.3512	E08.3513	E08.3521	E08.3522	E08.3523
E08.3531	E08.3532	E08.3533	E08.3541	E08.3542	E08.3543	E08.3551
E08.3552	E08.3553	E08.3591	E08.3592	E08.3593	E09.311	E09.319
E09.3211	E09.3212	E09.3213	E09.3291	E09.3292	E09.3293	E09.3311
E09.3312	E09.3313	E09.3391	E09.3392	E09.3393	E09.3411	E09.3412
E09.3413	E09.3491	E09.3492	E09.3493	E09.3511	E09.3512	E09.3513
E09.3521	E09.3522	E09.3523	E09.3531	E09.3532	E09.3533	E09.3541
E09.3542	E09.3543	E09.3551	E09.3552	E09.3553	E09.3591	E09.3592
E09.3593	E10.311	E10.319	E10.3211	E10.3212	E10.3213	E10.3291
E10.3292	E10.3293	E10.3311	E10.3312	E10.3313	E10.3391	E10.3392
E10.3393	E10.3411	E10.3412	E10.3413	E10.3491	E10.3492	E10.3493
E10.3511	E10.3512	E10.3513	E10.3521	E10.3522	E10.3523	E10.3531
E10.3532	E10.3533	E10.3541	E10.3542	E10.3543	E10.3551	E10.3552
E10.3553	E10.3591	E10.3592	E10.3593	E11.311	E11.319	E11.3211
E11.3212	E11.3213	E11.3291	E11.3292	E11.3293	E11.3311	E11.3312
E11.3313	E11.3391	E11.3392	E11.3393	E11.3411	E11.3412	E11.3413
E11.3491	E11.3492	E11.3493	E11.3511	E11.3512	E11.3513	E11.3521
E11.3522	E11.3523	E11.3531	E11.3532	E11.3533	E11.3541	E11.3542
E11.3543	E11.3551	E11.3552	E11.3553	E11.3591	E11.3592	E11.3593
E13.311	E13.319	E13.3211	E13.3212	E13.3213	E13.3291	E13.3292
E13.3293	E13.3311	E13.3312	E13.3313	E13.3391	E13.3392	E13.3393
E13.3411	E13.3412	E13.3413	E13.3491	E13.3492	E13.3493	E13.3511
E13.3512	E13.3513	E13.3521	E13.3522	E13.3523	E13.3531	E13.3532
E13.3533	E13.3541	E13.3542	E13.3543	E13.3551	E13.3552	E13.3553
E13.3591	E13.3592	E13.3593	E50.5	E50.9	F44.6	G45.3
H15.031	H15.032	H15.033	H20.011	H20.012	H20.013	H30.001
H30.002	H30.003	H30.011	H30.012	H30.013	H30.021	H30.022
H30.023	H30.031	H30.032	H30.033	H30.041	H30.042	H30.043
H30.101	H30.102	H30.103	H30.111	H30.112	H30.113	H30.121
H30.122	H30.123	H30.131	H30.132	H30.133	H30.141	H30.142
H30.143	H30.21	H30.22	H30.23	H30.811	H30.812	H30.813
H30.891	H30.892	H30.893	H30.91	H30.92	H30.93	H31.001
H31.002	H31.003	H31.011	H31.012	H31.013	H31.021	H31.022
H31.023	H31.091	H31.092	H31.093	H31.101	H31.102	H31.103
H31.111	H31.112	H31.113	H31.121	H31.122	H31.123	H31.20
H31.21	H31.22	H31.23	H31.29	H31.301	H31.302	H31.303
H31.311	H31.312	H31.313	H31.321	H31.322	H31.323	H31.401
H31.402	H31.403	H31.411	H31.412	H31.413	H31.421	H31.422
H31.423	H33.001	H33.002	H33.003	H33.011	H33.012	H33.013
H33.021	H33.022	H33.023	H33.031	H33.032	H33.033	H33.041
H33.042	H33.043	H33.051	H33.052	H33.053	H33.101	H33.102
H33.103	H33.111	H33.112	H33.113	H33.191	H33.192	H33.193
H33.21	H33.22	H33.23	H33.301	H33.302	H33.303	H33.311
H33.312	H33.313	H33.321	H33.322	H33.323	H33.331	H33.332
H33.333	H33.41	H33.42	H33.43	H33.8	H34.01	H34.02
H34.03	H34.11	H34.12	H34.13	H34.211	H34.212	H34.213
H34.231	H34.232	H34.233	H34.8110	H34.8111	H34.8112	H34.8120
H34.8121	H34.8122	H34.8130	H34.8131	H34.8132	H34.821	H34.822
H34.823	H34.8310	H34.8311	H34.8312	H34.8320	H34.8321	H34.8322
H34.8330	H34.8331	H34.8332	H34.9	H35.00	H35.012	H35.013
H35.021	H35.022	H35.023	H35.031	H35.032	H35.033	H35.041
H35.042	H35.043	H35.051	H35.052	H35.053	H35.061	H35.062
H35.063	H35.071	H35.072	H35.073	H35.09	H35.101	H35.102
H35.103	H35.111	H35.112	H35.113	H35.121	H35.122	H35.123
H35.131	H35.132	H35.133	H35.141	H35.142	H35.143	H35.151
H35.152	H35.153	H35.161	H35.162	H35.163	H35.171	H35.172
H35.173	H35.21	H35.22	H35.23	H35.30	H35.3110	H35.3111
H35.3112	H35.3113	H35.3114	H35.3120	H35.3121	H35.3122	H35.3123
H35.3124	H35.3130	H35.3131	H35.3132	H35.3133	H35.3134	H35.3210
H35.3211	H35.3212	H35.3213	H35.3220	H35.3221	H35.3222	H35.3223
H35.3230	H35.3231	H35.3232	H35.3233	H35.33	H35.341	H35.342
H35.343	H35.351	H35.352	H35.353	H35.361	H35.362	H35.363
H35.371	H35.372	H35.373	H35.381	H35.382	H35.383	H35.40
H35.411	H35.412	H35.413	H35.421	H35.422	H35.423	H35.431
H35.432	H35.433	H35.441	H35.442	H35.443	H35.451	H35.452
H35.453	H35.461	H35.462	H35.463	H35.50	H35.51	H35.52
H35.53	H35.54	H35.61	H35.62	H35.63	H35.70	H35.711
H35.712	H35.713	H35.721	H35.722	H35.723	H35.731	H35.732
H35.733	H35.81	H35.82	H35.89	H36	H44.2A1	H44.2A2
H44.2A3	H44.2B1	H44.2B2	H44.2B3	H44.2C1	H44.2C2	H44.2C3
H44.2D1	H44.2D2	H44.2D3	H44.2E1	H44.2E2	H44.2E3	H46.01
H46.02	H46.03	H46.11	H46.12	H46.13	H46.2	H46.3
H46.8	H46.9	H47.011	H47.012	H47.013	H47.021	H47.022
H47.023	H47.031	H47.032	H47.033	H47.091	H47.092	H47.093
H47.10	H47.11	H47.12	H47.13	H47.141	H47.142	H47.143
H47.20	H47.211	H47.212	H47.213	H47.22	H47.231	H47.232
H47.233	H47.291	H47.292	H47.293	H47.311	H47.312	H47.313
H47.321	H47.322	H47.323	H47.331	H47.332	H47.333	H47.391
H47.392	H47.393	H53.10	H53.11	H53.121	H53.122	H53.123
H53.131	H53.132	H53.133	H53.15	H53.16	H53.19	H53.411
H53.412	H53.413	H53.451	H53.452	H53.453	H53.51	H53.52
H53.60	H53.61	H53.62	H53.63	H53.69	H53.71	H53.72
H53.8	H53.9	H54.0X33	H54.0X34	H54.0X35	H54.0X43	H54.0X44
H54.0X45	H54.0X53	H54.0X54	H54.0X55	H54.1131	H54.1132	H54.1141
H54.1142	H54.1151	H54.1152	H54.1213	H54.1214	H54.1215	H54.1223
H54.1224	H54.1225	H54.2X11	H54.2X12	H54.2X21	H54.2X22	H54.413A
H54.414A	H54.415A	H54.42A3	H54.42A4	H54.42A5	H54.511A	H54.512A
H54.52A1	H54.52A2	H54.7	S04.011A	S04.011D	S04.011S	S04.012A
S04.012D	S04.012S	S05.51XA	S05.51XD	S05.51XS	S05.52XA	S05.52XD
S05.52XS	H36.811	H36.812	H36.813	H36.819	H36.821	H36.822
H36.823	H36.829	H36.89

Non-Covered Diagnosis Codes for Procedure Codes 0509T, 92273, and 92274

H40.10X0	H40.10X1	H40.10X2	H40.10X3	H40.10X4	H40.1110	H40.1111
H40.1112	H40.1113	H40.1114	H40.1120	H40.1121	H40.1122	H40.1123
H40.1124	H40.1130	H40.1131	H40.1132	H40.1133	H40.1134	H40.1190
H40.1191	H40.1192	H40.1193	H40.1194	H40.1210	H40.1211	H40.1212
H40.1213	H40.1214	H40.1220	H40.1221	H40.1222	H40.1223	H40.1224
H40.1230	H40.1231	H40.1232	H40.1234	H40.1290	H40.1291	H40.1292
H40.1293	H40.1294	H40.1310	H40.1311	H40.1312	H40.1313	H40.1314
H40.1320	H40.1321	H40.1322	H40.1323	H40.1324	H40.1330	H40.1331
H40.1332	H40.1333	H40.1334	H40.1390	H40.1391	H40.1392	H40.1393
H40.1394	H40.1410	H40.1411	H40.1412	H40.1413	H40.1414	H40.1420
H40.1421	H40.1422	H40.1423	H40.1424	H40.1430	H40.1431	H40.1432
H40.1433	H40.1434	H40.1490	H40.1491	H40.1492	H40.1493	H40.1494
H40.151	H40.152	H40.153	H40.159	H40.20X0	H40.20X1	H40.20X2
H40.20X3	H40.20X4	H40.211	H40.212	H40.213	H40.219	H40.2210
H40.2211	H40.2212	H40.2213	H40.2214	H40.2220	H40.2221	H40.2222
H40.2223	H40.2224	H40.2230	H40.2231	H40.2232	H40.2233	H40.2234
H40.2290	H40.2291	H40.2292	H40.2293	H40.2294	H40.231	H40.232
H40.233	H40.239	H40.241	H40.242	H40.243	H40.249	H40.30X0
H40.30X1	H40.30X2	H40.30X3	H40.30X4	H40.31X0	H40.31X1	H40.31X2
H40.31X3	H40.31X4	H40.32X0	H40.32X1	H40.32X2	H40.32X3	H40.32X4
H40.33X0	H40.33X1	H40.33X2	H40.33X3	H40.33X4	H40.40X0	H40.40X1
H40.40X2	H40.40X3	H40.40X4	H40.41X0	H40.41X1	H40.41X2	H40.41X3
H40.41X4	H40.42X0	H40.42X1	H40.42X2	H40.42X3	H40.42X4	H40.43X0
H40.43X1	H40.43X2	H40.43X3	H40.43X4	H40.50X0	H40.50X1	H40.50X2
H40.50X3	H40.50X4	H40.51X0	H40.51X1	H40.51X2	H40.51X3	H40.51X4
H40.52X0	H40.52X1	H40.52X2	H40.52X3	H40.52X4	H40.53X0	H40.53X1
H40.53X2	H40.53X3	H40.53X4	H40.60X0	H40.60X1	H40.60X2	H40.60X3
H40.60X4	H40.61X0	H40.61X1	H40.61X2	H40.61X3	H40.61X4	H40.62X0
H40.62X1	H40.62X2	H40.62X3	H40.62X4	H40.63X0	H40.63X1	H40.63X2
H40.63X3	H40.63X4	H40.811	H40.812	H40.813	H40.819	H40.821
H40.822	H40.823	H40.829	H40.831	H40.832	H40.833	H40.839
H40.89	H40.9	H42	Q15.0

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Electroretinography is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Links

Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.