The year 2020 shows great advancements in fundus photography for treating eye conditions, yet many insurance companies still have strict policies in place concerning medical necessity and coverage. When is fundus photography considered medically necessary? Understanding the qualifying diagnoses can prepare you and your patient for appropriate treatment options.

Eye care practitioners know that fundus photography can be extremely useful in the detection and monitoring of medical conditions, including glaucoma, high blood pressure, and multiple sclerosis. The process involves 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.

Determining Medical Necessity

Insurance companies may vary in what they consider a medical necessity. 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

Generally, 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, health insurance companies 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. Keep in mind, maintaining proper documentation is important for receiving coverage.

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. Be sure to label to 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!