Fundus photography can be extremely useful in the detection and monitoring of various medical conditions, including glaucoma, high blood pressure, multiple sclerosis, and more. Specifically, fundus photography refers to a process that involves taking high-quality photos of the retinas 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 when fundus photography is considered medically necessary and therefore covered by the policy. By having a better understanding of when fundus photography is categorized as a medical necessity, doctors and patients alike can make better-informed decisions about their eye exams and their health.

Determining Medical Necessity

Different insurance companies may vary slightly in what they consider a medical necessity, but in general, most carriers will deem fundus photography medically necessary in situations where the results of the comprehensive exam have a direct impact on the management or treatment of the patient. Most commonly, a medical necessity is generally granted when diagnosis or tracking 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. For example, even after an instance of glaucoma has already been diagnosed through other examination methods, a health insurance company may still cover fundus photography as part of a comprehensive eye exam if the photographs will help doctors determine the progression of the disease and inform treatment options. 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 who are looking for their health insurance policies to cover some or all of the cost of fundus photography should speak with their doctors to ensure that all required documentation is readily available. In most cases, this 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. All of this information is important in determining whether or not the photographs will be considered a medical necessity in each policyholder’s unique case.

Overall, fundus photography can be a valuable tool for monitoring the progression of various medical conditions so patients can get the treatment they need. Still, it’s important for patients and doctors alike to understand when fundus photography is considered a medical necessity and when it’s not. For more information on innovative fundus photography, contact Coburn Technologies today.