CommercialCoverageHigh impact
Extended Ophthalmoscopy (CPB 0767, reviewed 2025-12-02)
Aetna·Ophthalmology, Optometry·Medical Policy
Effective date
Dec 2, 2025
We identified it
Aug 15, 2026
Summary
Aetna has updated its Extended Ophthalmoscopy policy (CPB 0767) effective immediately, clarifying medical necessity criteria for CPT codes 92201 and 92202. The policy covers extended ophthalmoscopy with detailed retinal drawing for 30+ specific clinical indications (diabetic retinopathy, retinal detachment, macular degeneration, etc.) but explicitly excludes cases where routine ophthalmoscopy showed normal findings. Repeat procedures are covered only when clinical signs, symptoms, or conditions change. A lengthy list of 15+ conditions are deemed experimental/investigational and therefore non-covered.
Action Required
Effective immediately (December 2, 2025): Billing team must implement claim submission changes for Aetna members. (1) REQUIRE medical necessity documentation for CPT 92201 and 92202: Claims must include diagnosis codes from the covered ICD-10 list and documentation showing one of the 30+ covered indications (e.g., diabetic retinopathy, retinal detachment, macular degeneration). (2) DENY or HOLD claims for extended ophthalmoscopy when routine ophthalmoscopy documented normal findings—these are explicitly non-covered per policy. (3) DENY claims for experimental/investigational indications including: sickle cell disease, optic neuritis, Parkinson's disease, Alzheimer's disease, methotrexate/tamoxifen monitoring, fingolimod monitoring, checkpoint inhibitor monitoring, retinoblastoma screening, and ocular melanoma surveillance (unless supported by other covered criteria). (4) UPDATE billing software rules to require prior authorization or at minimum documentation submission before or concurrent with claim submission. (5) EDUCATE ophthalmology providers on the covered/non-covered indications list and requirement to document initial routine ophthalmoscopy findings. (6) TRAIN front desk and authorization staff to flag Aetna patients for potential pre-authorization requirements. Failure to comply will result in claim denials and patient balance liability.