Prior Authorization Review Panel MCO Policy Submission · 2020-02-10 · submission. Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:11/01/2019

Policy Number: 0689 Effective Date: Revision Date: 09/22/2017

Policy Name: Ocular Photoscreening

Type of Submission – Check all that apply:

New Policy Revised Policy*

Annual Review – No Revisions Statewide PDL

*All revisions to the pol icy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0689 Ocular Photoscreening

Clinical content waslast revisedon 09/22/2017. No additional non-clinical updates were made by Corporate since the last PARPsubmission.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

Proprietary Revised July 22, 2019

(https://www.aetna.com/)

Ocular Photoscreening

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Number: 0689

*Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers one ocular photoscreening medically necessary for screening all children 3

years of age, and for screening children 4 to 5 years of age who are unable to cooperate with

routine acuity screening (e.g., mental retardation, developmental delay, and severe behavioral

disorders).

Aetna considers retinal birefringence scanning for the detection of eye misalignment or

strabismus experimental and investigational because its effectiveness has not been established.

Last Review

03/12/2019

Effective: 08/13/2004

Next

Review: 07/25/2019

Review

History

Definitions

Additional

Clinical Policy

Bulletin

Notes

Many children permanently lose vision each year as a result of amblyopia, media opacities, and

treatable ocular disease processes. Early diagnosis and treatment of these conditions has been

shown to yield better visual outcomes.

The U.S. Preventive Services Task Force (USPSTF, 2011) 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. The USPSTF concluded that the current evidence is insufficient to assess the

balance of benefits and harms of vision screening for children less than 3 years of age.

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Infants and young preverbal children are difficult to screen because they are unable to provide

subjective responses to visual acuity testing and do not easily cooperate with testing of ocular

alignment or stereoacuity (AAP, 2002). For similar reasons, it also is difficult to screen certain

older children, such as those who are nonverbal or have developmental delays.

Ocular photoscreening has been used to screen for amblyogenic factors, such as strabismus,

media opacities, and significant refractive errors, in children (AAP, 2002). An advantage of

ocular photoscreening over standard methods of testing visual acuity, ocular alignment and

stereoacuity is that photoscreening requires little cooperation from the child, other than having to

fixate on the appropriate target long enough for photoscreening. Thus, photoscreening has the

potential to improve vision screening rates in preverbal children and those with developmental

delays who are the most difficult to screen. Many of the children that are most difficult to screen

using conventional methods are also at highest risk of amblyopia (e.g., premature infants,

children with developmental delays).

Ocular photoscreening uses a specialized camera or video system to obtain images of the

pupillary reflexes and red reflexes (AAP, 2002). An evaluator, reviewing center or computer

analyzes data for amblyogenic factors. Children with abnormal findings are referred for a

complete eye examination.

Two types of photoscreeners are presently available: (i) those in which the screener interprets

the photograph (such as MTI Photoscreener™, Medical Technology and Innovations, Inc.,

Lancaster, PA; Visiscreen 100™, Vision Research Corporation, Birmingham, AL) and (ii) those

in whi ch a computer interprets the photograph (such as The EyeDx System™, EyeDx, Inc.,

San Diego, CA).

In a position statement on instrument-based pediatric vision screening, the American Academy

of Pediatrics Section on Ophthalmology and the Committee on the Practice of Ambulatory

Medicine (Miller et al, 2012) stated that photoscreening and handheld autorefraction may be

electively performed in children to 3 years of age, allowing earlier detection of conditions that

may lead to amblyopia, as well as in older children who are unable to cooperate with routine

acuity screening. The position statement was issued in conjunction with the American Academy

of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and

the American Association of Certified Orthoptists. The statement noted that instrument-based

screening is quick, requires minimal cooperation of the child, and is especially useful in the

preverbal, preliterate, or developmentally delayed child. The statement said that children

younger than 4 years can benefit from instrument-based screening, and visual acuity testing can

be used reliably in older children.



The U.S. Preventive Services Task Force (USPSTF, 2011) 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. 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 less than 3 years of age leads to improved visual outcomes.

The U.S. Preventive Services Task Force recommendations discuss ocular photoscreening

among several methods of vision screening of children. The Recommendation Statement states:

“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)”. The USPSTF noted that

potential disadvantages of using photoscreeners and autorefractors are the initial high costs

associated with the instruments and the need for external interpretation of screening results with

some photoscreeners.

The USPSTF evidence review (Chou et al, 2011) identified 26 studies, including 3 of poor quality

and 23 of fair quality, that evaluated the diagnostic accuracy of various preschool vision

screening tests. The USPSTF review reported, however, that none of the tests was associated

consistently with both high sensitivity and high specificity (i.e., 90 %) for specific amblyogenic

risk factors. Vision screening tests included tests of visual acuity, stereoacuity, and ocular

alignment, as well as tests using autorefractors and photoscreeners. The largest study

comparing screening tests was the Vision in Preschoolers study (Schmidt et al, 2004; Ying et al,

2005), which compared 10 different screening tests. In the Vision in Preschoolers study, the

Random Dot E stereoacuity test (StereoOptical Co, Chicago, IL), the Randot Stereo Smile Test II

(Stereo-Optical Co, Chicago, IL), and the iScreen (iScreen, Inc, Memphis, TN) and Medical

Technologies, Inc photoscreeners (Riviera Beach, FL) were associated with lower sensitivity (at

a similar specificity), compared with the Lea symbols test (Precision Vision, Inc, LaSalle, IL), the

HOTV visual acuity test (Precision Vision, Inc, LaSalle, IL), and the Retinomax (Nikon, Inc,

Melville, NY) and Power Refractor II (Plusoptix, Nuremberg, Germany) autorefractors. The

USPSTF report stated, however, that differences in likelihood ratio estimates were relatively

small. The USPSTF concluded that well-designed studies are needed to identify the optimal age

for initiation of screening, optimal screening methods, optimal screening frequency, and the most

favorable combinations of screening tests.



Bright Futures does not recommend ocular photoscreening for vision screening (Kemper &

Delmonte, 2010). Bright Future states that: “New vision screening technology (e.g.,

photoscreening, autorefraction) has been developed and is increasingly used in pediatric

practice. Recommendations for the use of such technology will be made as evidence regarding

their comparative effectiveness becomes available”.

An evidence review prepared for the Agency for Healthcare Research and Quality (2004) found

that the reports of the accuracy of ocular photoscreening are promising, but no evaluation has

been done in the primary care practice setting with the tests administered as would be done by

those usually responsible for screening. Additionally, little is known about how these new tests

compare to the physical examination itself.

A technology assessment of preschool vision screening by the Canadian Agency for Drugs and

Technologies in Health (Dunfield and Keating, 2007) found that, with photoscreening,

sensitivities ranged from 27.8 % to 88 %, and specificities ranged from 40 % to 98.5 % in

different studies. The technology assessment found that no single test or group of tests has

been shown to be superior for preschool vision screening.

The Canadian Paediatric Society (2009) stated that "there appears to be some agreement on the

cost-effectiveness as well as the efficacy of photoscreening in preschoolers". The guidelines

cited large studies demonstrating positive predictive values of ocular photoscreening of over

80 % (citing Donahue et al, 2006) and over 95 % (citing Arnold et al, 2005). The guidelines

noted, however, that "the negative predictive value of these rather large studies has not been

clearly established; therefore, the safety of this promising technology remains unknown

compared with conventional methods". The guidelines state that ocular photoscreening "is not

appropriate for office-based primary care and assessment of infants and children."

In a multi-center, randomized controlled study, Salcido et al (2005) compared the usefulness of

traditional vision screening and photoscreening of 3- and 4-year-old children in the pediatrician's

office. Following training of pediatricians and office staff, 6 pediatric clinics used both the MTI

PhotoScreener (Medical Technology Industries, LLC, Riviera Beach, FL) and traditional acuity

and stereopsis screening materials (HOTV charts/Random Dot E tests as recommended by

established AAP-MCHB-PUPVS guidelines) during well-child examinations. Clinics used one

testing method for a 6-month period and switched to the other for the following 6 months, in a

randomized manner. Referred children received a complete eye examination with cycloplegic

refraction by local ophthalmologists or optometrists who forwarded the results to Vanderbilt

Ophthalmology Outreach Center. Amblyogenic factors were defined using standardized

published criteria. A total of 605 children were screened with the photoscreener and 447 were

screened with traditional techniques. Mean time for screening was less with the photoscreener:



2.5 versus 5.9 minutes (p < 0.01). Untestable rates were similar (18 % versus 10%, respectively

p = NS), but higher with the photoscreener due to one clinic's 70 % unreadable rate. Referral

rates were also similar: 3.8 % versus 4.5 %. The positive predictive value (PPV) rate differed

greatly. With follow-up results obtained from 56 % of referred children, 73 % of photoscreening

referred children (8/11 examined) had amblyogenic factors confirmed on formal eye

examinations, whereas all children referred using traditional screening methods (10/10

examined) were normal. These authors concluded that photoscreening is more time efficient

than traditional screening and has a significantly higher PPV in 3- and 4-year-old children.

However, this study was unable to validate traditional screening techniques in this pre-school

age group. The authors further stated that if these results can be replicated, support for

traditional vision screening must undergo intense scrutiny, and attention should be turned toward

making photoscreening feasible for widespread implementation.

In a case series study, Teed et al (2010) examined the effectiveness of amblyopia treatment in

children identified through a community photoscreening program. These researchers included

125 children diagnosed with amblyopia after referral from a photoscreening program. Treatment

regimens included spectacles, patching, and/or atropine penalization. Successful treatment was

defined as greater than or equal to 3 Snellen line equivalent improvement in visual acuity

(VA) and/or 20/30 VA in the amblyopic eye in literate children. Successful treatment in initially

pre-literate children was defined as 20/30 or better VA in the amblyopic eye. Main outcome

measure was percentage of successfully treated amblyopic children. Of 901 children evaluated

after being referred from photoscreening, 551 had amblyopiogenic risk factors without

amblyopia, 185 were diagnosed with amblyopia, and 165 were false-positives. Of 185 children

with amblyopia, 125 met inclusion criteria for analysis and 78 % (97 of 125) were successfully

treated. The authors concluded that the success rate of amblyopia treatment in children

identified through the authors' photoscreening program is high. They noted that these findings

support the role of photoscreening programs in the prevention of amblyopia-related vision loss.

Such early screening may translate to true VA improvement. The drawbacks of this study

include (i) non-standardized VA measurements, (ii) variability in amblyopic treatment, and

(iii) uncertainty in the diagnosis and treatment of amblyopia in pre-literate children.

Yanovitch and colleagues (2010) determined the sensitivity, specificity, and positive and negative

predictive values of photoscreening in detecting treatable ocular conditions in children with Down

syndrome (DS). Photoscreening and complete ophthalmologic evaluations were performed in 50

consecutive 3- to 10-year-old children with DS. Sensitivity, specificity, and positive and negative

predictive values were calculated with the use of ophthalmologic examination findings as the

reference standard. Most children were able to complete photoscreening (94 % with Medical

Technology and Innovations [MTI] and 90 % with Visiscreen OSS-C [VR]). Many children had an



identified diagnosis on ophthalmologic examination (n = 46, 92 %). Of these, approximately one-

half (n = 27, 54 %) had one or more condition(s) requiring treatment. Both the MTI and VR

photoscreening devices had a sensitivity of 93 % (95 % confidence interval [CI]: 0.76 to 0.99) for

detecting treatable ocular conditions. The specificities for the MTI and VR photoscreening were

0.35 (CI: 0.18 to 0.57) and 0.55 (CI: 0.34 to 0.74), respectively. The authors concluded that

photoscreening is sensitive but less specific at detecting treatable ocular conditions in children

with DS. In specific instances, the use of photoscreening in the DS population has the potential

to save time and expense related to routine eye examinations, especially in children with a

normal baseline comprehensive examination.

Retinal Birefringence Scanning

Retinal birefringence scanners (RBS) (e.g., the Pediatric Vision Scanner [PVS]) are hand-held

instruments that measure the changes in the polarization of light returning from the eye to detect

eye misalignment or strabismus during a brief scan of theeye.

Nassif and associates (2006) evaluated the clinical performance of the PVS in children in a

pediatric ophthalmology office setting. A total of 77 subjects between 2 and 18 years of age

received gold-standard orthoptic examinations and were classified as at risk for amblyopia if

strabismus or anisometropia (greater than 1.50 diopters) was present. Strabismus was sub-

classified as variable or constant. The subjects were then tested with the PVS, which produced

a pass or refer recommendation based on a binocularity score. The PVS also produced a yield

score to indicate the subject's interest in the target. Sensitivity and specificity for amblyopia risk

detection were calculated. Binocularity as determined by the PVS was greater than 65 % for all

controls and less than 20 % for all subjects with constant strabismus. Binocularity ranged from 0

% to 52 % in subjects with variable strabismus. All subjects with anisometropia and no

strabismus had binocularity scores less than 10 %. The authors concluded that PVS identified

strabismus, when present, in all subjects and identified 3 subjects with anisometropia as well.

They stated that the instrument showed potential as a screening device for amblyopia risk

factors in pre-school children for use by primary care physicians and nurses. They stated that

future studies will better characterize its performance in subjects with anisometropia, mono-

fixation syndrome, and uncomplicated, symmetric refractive error.

Loudon and co-workers (2011) evaluated the ability of the PVS to identify patients with

amblyopia or strabismus, particularly anisometropic amblyopia with no measurable strabismus.

The PVS test, administered from 40 cm and requiring 2.5 seconds of attention, generated a

binocularity score (BIN, 0 % to 100 %). These investigators tested 154 patients and 48 controls

between the ages of 2 and 18 years; BIN scores of amblyopic children and controls were

measured, and 21 children received sequential PVS measurements to detect any changes in



BIN resulting from amblyopia treatment. With the pass/refer threshold set at BIN 60 %,

sensitivity and specificity were 96 % for the detection of amblyopia or strabismus. Assuming a 5

% prevalence of amblyopia or strabismus, the inferred positive and negative predictive values of

the PVS were 56 % and 100 %, respectively. Fixation accuracy was significantly reduced in

amblyopic eyes. In anisometropic amblyopia patients treated successfully, the BIN improved to

100 %. The authors concluded that the PVS identified children with amblyopia or strabismus

with high sensitivity and specificity, while successful treatment restored normal BIN scores in

amblyopic patients without strabismus. They stated that these findings supported the hypothesis

that the PVS detects strabismus and amblyopia directly. They stated that future strategies for

screening by non-specialists may thus be based on diagnostic detection of amblyopia and

strabismus rather than the estimation of risk factors, allowing for rapid, accurate identification of

children with amblyopia early in life when it is most amenable to treatment. The drawbacks of

this study included small sample size (n = 21 received PVS measurements), single-center, as

well as engagement of patients with known risk factors.

Jost and colleagues (2015) examined the specificity of the PVS, a binocular retinal birefringence

scanner, in its intended setting, a pediatric primary care office. A total of 102 pre-school children

(aged 2 to 6 years) were screened during a well-child pediatric visit using the PVS and the

SureSight Auto-refractor and completed a masked comprehensive pediatric ophthalmic

examination (gold standard examination). Based on the gold standard examination, 1 child had

anisometropic amblyopia, and the remaining 101 had no amblyopia or strabismus. Specificity of

the PVS was 90 % (95 % CI: 82 % to 95 %) while specificity of the SureSight was 87 % (95 %

CI: 79 % to 93 %). Combining these results with the sensitivity of the devices determined in a

previous study conducted in a pediatric ophthalmology office setting, the positive likelihood ratio

for the PVS was 10.2; for the SureSight, 5.0. The negative likelihood ratio for the PVS was 0.03;

for the SureSight, 0.42, a significant difference. The authors concluded that the PVS had high

specificity (90 %) in screening for amblyopia and strabismus as part of a pediatric well-child visit.

Likelihood ratio analysis suggested that affected children have a high probability of being

correctly identified by the PVS. The high level of confidence conferred by PVS screening may

remove an important barrier to vision screening in pediatric primary care.

Gramatikov and associates (2016) noted that many devices for eye diagnostics and some

devices for eye therapeutics require the patient to fixate on a small target for a certain period of

time, during which the eyes do not move and data from substructures of 1 or both eyes are

acquired and analyzed. With pediatric patients, a monotonously blinking target is not sufficient to

retain attention steadily. These researchers developed a method for modulating the intensity of a

point fixation target using sounds appropriate to the child's age and preference. The method

was realized as a subsystem of a PVS that employs RBS for detection of central fixation. In this

study, a total of 21 subjects, aged 2 to 18 years, were studied. Modulation of the fixation target



using sounds ensured the eye fixated on the target, and with appropriate choice of sounds,

performed significantly better than a monotonously blinking target accompanied by a plain beep.

The method was particularly effective with children of ages up to 10 years, after which its benefit

disappeared. Typical applications of target modulation would be as supplemental subsystems in

pediatric ophthalmic diagnostic devices, such as scanning laser ophthalmoscopes, optical

coherence tomography units, RBS, fundus cameras, and perimeters. This was a small study;

and its findings need to be validated by well-designedstudies.

In a systematic review on “Vision screening in children ages 6 months to 5 years”, Jonas et al

(2017), on behalf of the USPSTF, found 34 fair-quality studies (n = 45,588 observations) that

evaluated the accuracy of various screening tests: visual acuity tests (6 studies), stereo-acuity

tests (4 studies), ocular alignment tests (1 study), a combination of clinical tests (4 studies), auto

refractors (16 studies), photo-screeners (11 studies), and RBS (1study).

There is currently insufficient evidence to support the use of retinal birefringence scanning; well-

designed studies with larger sample sizes including the general population are needed to

ascertain its clinical value.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes covered if selection criteria are met:

99174 Instrument-based ocular s creening (eg, photoscreening, automated-refraction),

bilateral; with r emote analysis and report

99177 with on-site analysis

CPT codes not covered for indications listed in the CPB:

0469T Retinal polarization scan, ocular screening with on-site automated results, bilateral

ICD-10 codes covered if selection criteria are met (not all-inclusive):

H52.00 - H52.7 Disorders of refraction and accommodation

H53.001 - H54.8 Visual disturbances, blindness and low vision

P07.00 - P07.32 Disorders of newborn r elated to short gestation and low birth weight, not elsewhere

classified

Z00.129 Encounter for routine child health examination without abnormal findings

Z01.00 - Z01.01 Encounter for examination of eyes and vision



Z02.0 - Z02.3,

Z02.89

Encounter for administrative examination

Z13.5 Encounter for screening for eye and ear di sorders

ICD-10 codes not covered for indications listed in the CPB:

H49.00 - H49.9 Paralytic strabismus

H50.00 - H50.9 Other strabismus

Z00.110 - Z00.129 Encounter for newborn, infant and child health examinations

Z01.00 - Z01.01 Encounter for examination of eyes and vision

Code Code Description

1. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and

Section on Ophthalmology. Use of photoscreening for children's vision screening. Policy

Statement. Pediatrics. 2002;109(3):524-525.

2. American Academy of Pediatrics. AAP publications reaffirmed and retired, February and

May 2008. Pediatrics 2008; 122(2):450.

3. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and

Section on Ophthalmology. Eye examination and vision screening in infants, children, and

young adults. Policy Statement. Pediatrics. 1996;98:153–157.

4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Section

on Ophthalmology; American Association of Certified Orthoptists; American Association for

Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Eye

examination in infants, children, and young adults by pediatricians. Pediatrics. 2003;111(4

Pt 1):902-907.

5. Enzenauer RW, Freeman HL, Larson MR, Williams TL. Photoscreening for amblyogenic

factors by public health personnel: The Eyecor Camera System. Ophthalmic Epidemiol.

2000;7(1):1-12.

6. Watts P, Walker K, Beck L. Photoscreening for refractive errors in children and young adults

with severe learning disabilities using the MTI photoscreener. Eye. 1999;13 ( Pt 3a):363

368.

7. Granet DB, Hoover A, Smith AR, et al. A new objective digital computerized vision

screening system. J Pediatr Ophthalmol Strabismus. 1999;36(5):251-256.

8. Cooper CD, Bowling FG, Hall JE, et al. Evaluation of photoscreener instruments in a

childhood population. 1. Otago photoscreener and Dortmans videophotorefractor. Aust N Z



J Ophthalmol. 1996;24(4):347-355.

9. Molteno AC, Hoare-Nairne J, Sanderson GF, et al. Reliability of the Otago photoscreener. A

study of a thousand cases. Aust N Z J Ophthalmol. 1993;21(4):257-265.

10. Maslin K, Hope C. Photoscreening to detect potential amblyopia. Aust N Z J Ophthalmol.

1990;18(3):313-318.

11. Kennedy RA, Sheps SB. A comparison of photoscreening techniques for amblyogenic

factors in children. Can J Ophthalmol. 1989;24(6):259-264.

12. Kemper A, Harris R, Lieu TA,et al. Screening for visual impairment in children younger than

age 5 years. Systematic Evidence Review No. 27 (Prepared by the Research Triangle

Institute-University of North Carolina Evidence-based Practice Center under Contract No.

290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); May

2004.

13. Nelson H, Nygren P, Huffman L, et al. Screening for visual impairment in children younger

than age 5 years: Update of the evidence from randomized controlled trails, 1999-2003, for

the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research

and Quality (AHRQ); May 2004.

14. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and

Section on Ophthalmology, American Association of Certified Orthoptists, American

Association of Pediatric Ophthalmology and Strabismus, American Academy of

Ophthalmology. Eye examination in infants, children, and young adults by pediatricians:

Policy statement. Pediatrics. 2003;111(4):902-907.

15. U.S. Preventive Services Task Force (USPSTF). Screening for visual impairment in children

younger than age 5 years: Recommendation statement. Rockville, MD: Agency for

Healthcare Research and Quality (AHRQ); 2004.

16. Schmidt P, Maguire M, Dobson V, et al. Comparison of preschool vision screening tests as

administered by licensed eye care professionals in the Vision in Preschoolers study.

Ophthalmology. 2004;111(4):637– 650.

17. Ying GS, Kulp MT, Maguire M, et al. Sensitivity of screening tests for detecting Vision in

Preschoolers-targeted vision disorders when specificity is 94%. Optom Vis Sci.

2005;82(5):432– 438.

18. Salcido AA, Bradley J, Donahue SP. Predictive value of photoscreening and traditional

screening of preschool children. J AAPOS. 2005;9(2):114-120.

19. Arnold RW, Armitage MD, Gionet EG, et al. The cost and yield of photoscreening: impact of

photoscreening on overall pediatric ophthalmic costs. J Pediatr Ophthalmol Strabismus.

2005;42(2):103-111.

20. American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

Photoscreening to detect amblyogenic factors (AAPOS photoscreening position statement).



San Francisco, CA: AAPOS; 2005. Available at: http://www.aapos.org/displaycommon.cfm?

an=1&subarticlenbr=104. Accessed October 5, 2006.

21. Chen YL, Lewis JW, Kerr N, Kennedy RA. Computer-based real-time analysis in mobile

ocular screening. Telemed J E Health. 2006;12(1):66-72.

22. Donahue SP, Baker JD, Scott WE, et al. Lions Clubs International Foundation Core Four

Photoscreening: Results from 17 programs and 400,000 preschool children. J AAPOS.

2006;10(1):44-48.

23. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Pediatric

eye evaluations: I. Screening; II. Comprehensive ophthalmic evaluation. San Francisco,

CA: American Academy of Ophthalmology; 2007.

24. Dunfield L, Keating T. Preschool vision screening. Technology Report No. 73. Ottawa, ON:

Canadian Agency for Drugs and Technologies in Health (CADTH); February 2007.

25. Carlton J, Karnon J, Czoski-Murray C, et al. The clinical effectiveness and cost-

effectiveness of screening programmes for amblyopia and stabismus in children up to the

ages of 4-5 years: A systematic review and economic evaluation. Health Technol Assess.

2008;12(25):1-214.

26. Canadian Paediatric Society, Community Paediatrics Committee. Vision screening in

infants, children and youth. Paediatr Child Health. 2009;14(4):246–248.

27. Teed RG, Bui CM, Morrison DG, et al. Amblyopia therapy in children identified by

photoscreening. Ophthalmology. 2010;117(1):159-162.

28. Yanovitch T, Wallace DK, Freedman SF, et al. The accuracy of photoscreening at detecting

treatable ocular conditions in children with Down syndrome. J AAPOS. 2010;14(6):472-477.

29. Kemper A, Delmonte MA. Vision. In: Performing Preventive Services: A Bright Futures

Handbook. S Tanski, LC Garfunkel, PM Duncan, M Weitzman, eds. Elk Grove Village, IL:

American Academy of Pediatrics; 2010, pp.155-157.

30. U.S. Preventive Services Task Force (USPSTF). Screening for visual impairment in children

ages 1 to 5 years. Recommendations of the U.S. Preventive Services Task Force.

Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); January 2011.

31. Chou R, Dana T, Bougatsos C. Screening for visual impairment in children ages 1–5 years:

Systematic review to update the 2004 U.S. Preventive Services Task Force

Recommendation. Evidence Synthesis No. 81. Rockville, MD: Agency for Healthcare

Research and Quality; 2011.

32. Chou R, Dana T, Bougatsos C. Screening for visual impairment in children ages 1–5 years:

Update for the USPSTF. Pediatrics. 2011;127(2):e442– e479.

33. Miller JM, Lessin HR; American Academy of Pediatrics, Committee on Practice and

Ambulatory Medicine, Section on Ophthalmology; American Association of Certified

Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American



http://www.aapos.org/displaycommon.cfm

Academy of Ophthalmology. Instrument-based pediatric vision screening policy

statement. Policy Statement. Pediatrics. 2012;130(5):983-986,

34. McCurry TC, Lawrence LM, Wilson ME, Mayo L. The plusoptiX S08 photoscreener as a

vision screening tool for children with autism. J AAPOS. 2013;17(4):374-377.

35. Silbert D, Matta N, Tian J, Singman E. Comparing the SureSight autorefractor and the

plusoptiX photoscreener for pediatric vision screening. Strabismus. 2014;22(2):64-67.

36. Silbert DI, Matta NS. Performance of the Spot vision screener for the detection of

amblyopia risk factors in children. J AAPOS.2014;18(2):169-172.

37. Arnold RW, Armitage MD. Performance of four new photoscreeners on pediatric patients

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and

constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or

program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any

results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna

or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be

updated and therefore is subject to change.

Copyright © 2001-2019 Aetna Inc.



AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical PolicyBulletin Number: 0689

Ocular Photoscreening

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 11/01/2019

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission · 2020-02-10 · submission. Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany