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Extended Ophthalmoscopy (CPB 0767, reviewed 2026-10-28)
Effective date
Not stated in the notice
Identified
Nov 2, 2026
Summary
Aetna's Extended Ophthalmoscopy policy (CPB 0767) was reviewed on 2026-10-28 and establishes medical necessity criteria for CPT codes 92201 and 92202. The policy covers extended ophthalmoscopy with detailed retinal drawing for specific clinical indications (such as diabetic retinopathy, retinal detachment, glaucoma, and high myopia) but explicitly excludes cases where routine ophthalmoscopy showed normal findings. The policy also lists indications deemed experimental/investigational (such as monitoring certain medications, neurodegenerative diseases, and retinoblastoma screening) where extended ophthalmoscopy is not covered.
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What to do
Action · 5 steps
01Confirm the practice's current charge entry and prior authorization processes align with Aetna's medical necessity criteria for CPT 92201 and 92202.
02Before billing extended ophthalmoscopy for Aetna members, verify that the clinical documentation supports one of the covered indications listed in the policy (e.g., diabetic retinopathy, retinal detachment, glaucoma, high axial length myopia ≤ -6.00 Diopters, sudden/transient visual loss, retinal hemorrhage, or other specified posterior segment pathology).
03Do not bill CPT 92201 or 92202 when routine ophthalmoscopy alone showed normal clinical findings, as claims will be denied.
04For indications listed as experimental/investigational (e.g., monitoring fingolimod, methotrexate, checkpoint inhibitors; Alzheimer's disease; sickle cell disease; optic neuritis; or retinoblastoma screening), do not bill these codes to Aetna, as coverage is not established.
05Update documentation templates and provider education to ensure the clinical record explicitly ties the extended ophthalmoscopy to a covered indication before submitting claims.
Codes mentioned
9220192202
Original notice
Extended Ophthalmoscopy (CPB 0767, reviewed 2026-10-28)
aetna.com · Always check the source before changing claims.
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