Prior Authorization Review Panel MCO Policy Submission · 2020-02-10 · submission. Prior...
Transcript of Prior Authorization Review Panel MCO Policy Submission · 2020-02-10 · submission. Prior...
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.
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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.
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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:
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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
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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
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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
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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
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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
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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).
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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
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Academy of Ophthalmology. Instrument-based pediatric vision screening policy
statement. Policy Statement. Pediatrics. 2012;130(5):983-986,
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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.
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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