CommercialCoverageMedium impact
Endothelial Cell Photography (CPB 0538, reviewed 2025-11-26)
Aetna·Ophthalmology, Optometry·Medical Policy
Effective date
Jun 29, 2001
We identified it
Aug 14, 2026
Summary
Aetna's updated CPB 0538 policy clarifies medical necessity criteria for endothelial cell photography (CPT 92286, 92287) for specific pre-surgical and corneal conditions. The policy establishes seven specific clinical indications where the procedure is covered, and designates it as an integral part of pre-surgical eye exams for cataract surgery when appropriate. All other indications remain experimental/investigational.
Action Required
By December 26, 2025: Billing team must review and implement updated medical necessity criteria for endothelial cell photography (CPT 92286, 92287) claims submitted to Aetna. Update billing software validation rules to accept claims ONLY when one of the seven documented indications is present: (1) extended wear contact lens fitting post-intraocular surgery, (2) secondary IOL implantation planned, (3) higher-risk corneal endothelium surgical procedure planned, (4) prior intraocular surgery with cataract surgery needed, (5) slit-lamp evidence of corneal edema, (6) slit-lamp evidence of endothelial dystrophy/Fuch's dystrophy, or (7) posterior polymorphous dystrophy or irido-corneal endothelium syndrome. Ensure provider documentation templates capture the specific clinical indication on encounter notes. For all other indications, flag claims as experimental/investigational and deny or require prior authorization per plan terms. Failure to align with these criteria will result in claim denials from Aetna.