Coverage Policy Manual
Policy #: 2011033
Category: PPACA Preventive
Initiated: September 2010
Last Review: October 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: VISUAL IMPAIRMENT SCREENING IN CHILDREN

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
Visual screening to detect amblyopia, strabismus and defects in visual acuity is covered in children 5 years of age or younger for members of “non-grandfathered” plans on an annual basis, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these services are V20.2, V72.0 and V80.2.
 
The appropriate ICD-10 codes to report this service are Z00.121, Z00.129, Z01.00-Z01.01 and Z13.5.
 
This service is typically part of a normal wellness office visit.
 
CPT code 99173, 99174 or 99177 may be used to report the visual screening. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 

Rationale:
The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors (Grade B Recommendation).
 
The USPSTF recommendations include the following information:
 
    • Approximately 2% to 4% of preschool-aged children have amblyopia, an alteration in the visual neural pathway in the developing brain that can lead to permanent vision loss in the affected eye. Amblyopia usually occurs unilaterally but can occur bilaterally. Identification of vision impairment before school entry could help identify children who may benefit from early interventions to correct or to improve vision.
    • The USPSTF found adequate evidence that vision screening tools have reasonable accuracy in detecting visual impairment, including refractive errors, strabismus, and amblyopia.
    • The USPSTF found adequate evidence that early treatment for amblyopia, including the use of cycloplegic agents, patching, and eyeglasses, for children 3 to 5 years of age leads to improved visual outcomes. The USPSTF found inadequate evidence that early treatment of amblyopia for children <3 years of age leads to improved visual outcomes.
    • The USPSTF found limited evidence regarding harms of screening, including psychosocial effects, for children ≥3 years of age. False-positive screening results may lead to the overprescribing of corrective lenses. Adequate evidence suggests that the harms of treatment of amblyopia for children ≥3 years of age are limited to reversible loss of visual acuity resulting from patching of the nonaffected eye. The USPSTF found inadequate evidence of the harms of screening and treatment for children <3 years of age.
    • The USPSTF concludes with moderate certainty that vision screening for children 3 to 5 years of age has a moderate net benefit. The USPSTF concludes that the benefits of vision screening for children <3 years of age are uncertain and that the balance of benefits and harms cannot be determined for this age group.
    • Various screening tests that are feasible in primary care are used to identify visual impairment among children. These tests include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors).
    • Primary treatment for amblyopia includes the use of corrective lenses, patching, or atropine treatment of the nonaffected eye. Treatment may consist of a combination of interventions.
    • The USPSTF did not find adequate evidence to determine the optimal screening interval.
    • Several gaps in the evidence were identified. All treatment trials in the literature review enrolled children ≥3 years of age. Well-designed studies are needed to identify the optimal age for initiation of screening, optimal screening methods, and optimal screening frequency. Longitudinal studies that link optimal screening tests to the identification of children with visual impairments are needed. Additional studies are needed to determine the most-favorable combinations of screening tests, as well as the optimal treatment for amblyopia and the optimal treatment duration. There also is a need for studies that examine the long-term benefits and harms of preschool vision screening, such as quality of life, school performance, and labeling or anxiety.
 

CPT/HCPCS:
99173Screening test of visual acuity, quantitative, bilateral
99174Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report
99177Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.

Screening for lipid disorders in adults.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvsch.htm. Last accessed May 2011.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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