Fundus photography can be extremely useful in the detection and monitoring of various medical conditions, including glaucoma, high blood pressure, multiple sclerosis, and more. The process involves taking high-quality photos of the retina using the eye’s own reflective properties. Key to any comprehensive eye exam, fundus photography is completely painless for the patient, doesn’t typically require dilation of the pupils, and delivers extremely detailed and accurate results.

Many insurance companies have strict policies in place when it comes to fundus photography, and if it is considered medically necessary to be covered by the policy. Having a baseline understanding of qualifying diagnoses can better prepare the patient for treatment options.

Determining Medical Necessity

Insurance companies may vary slightly in what they consider a medical necessity. In most cases, fundus photography is deemed medically necessary if the results are predicted to have a direct impact on the management or treatment of the patient. Medical necessity is usually granted when eye care practitioners diagnose or track the progression of the following:

  • Carcinoma in situ of the eye
  • Glaucoma
  • HIV disease
  • Retinal detachment
  • Sickle-cell anemia
  • Multiple sclerosis

In general, fundus photographs aren’t medically necessary to establish the existence of a condition, but are necessary in determining the progression of a disease. If glaucoma has already been diagnosed through other examination methods, a health insurance company may still cover fundus photography as part of the comprehensive eye exam. If resulting photographs help identify progression of the disease and inform treatment options, it will be covered. This can sometimes be a difficult distinction for doctor’s offices and insurance companies to make, which is why proper documentation is so important.

Documentation for Fundus Photography Coverage

Patients seeking partial or complete coverage for the cost of fundus photography will require proper documentation. In most cases, the required documentation will include:

  • Current history and diagnosis
  • Results of physical examination
  • Progress notes supporting need for fundus photographs
  • Reports of prior diagnostic testing

If the fundus photographs have already been taken, then these should also be included within the documentation. Specifically, they should be labeled to indicate which photographs correspond to which eye, the sequence in which the photos were taken, and the date they were reviewed. This information is important in determining whether or not the photographs will be considered a medical necessity in each policyholder’s unique case.

Fundus photography is a valuable tool for monitoring the progression of various medical conditions so patients can get the treatment they need. Explore our fundus camera options and let us know if you’d like to incorporate one into your practice!