TN 8 (11-12)

DI 23022.979 Retinopathy of Prematurity- Stage V

COMPASSIONATE ALLOWANCE INFORMATION

RETINOPATHY OF PREMATURITY- STAGE V

ALTERNATE NAMES

ROP Stage V; Retinopathy of Prematurity Type V; Retrolental Fibroplasia

DESCRIPTION

Retinopathy of Prematurity (ROP) is abnormal blood vessel development in the retina of very low birth weight premature infants. ROP occurs when abnormal blood vessels grow and spread throughout the retina, and the tissue that lines the back of the eye. These abnormal blood vessels are fragile and can leak blood, scarring the retina and pulling it out of position. There are five stages of ROP, with Stage V being the most severe due to complete retinal detachment causing visual impairment and blindness.

DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM CODING

Diagnostic testing: (for older children) visual acuity and visual fields testing.

Physical findings: Complete ophthalmologic eye examination, including the diagnostic retinal staging of ROP with total retinal detachment.

ICD-9: 362.27

ONSET AND PROGRESSION

Severe ROP (stage V) may lead to significant vision problems or blindness. Infants with Stage V ROP have total retinal detachment with very poor visual prognosis.

TREATMENT

Surgical treatment options for advanced ROP include laser treatments, cryotherapy, “scleral buckle” (which requires later procedures to remove the inserted silicon band), and vitrectomy.

SUGGESTED PROGRAMMATIC ASSESSMENT*

Suggested MER for evaluation:

  • Clinical history and examination that describes the diagnostic features and physical findings.

  • Pediatric ophthalmological examination indicating total retinal detachment.

  • (For older children) visual acuity and visual fields testing.

Suggested Listings for Evaluation:

DETERMINATION

LISTING

REMARKS

Meets Listing

102.02 A or B

102.03 A or B or C

102.04

 

Medical Equals

  

* Adjudicators may, at their discretion, use the Medical Evidence of Record or Listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022979
DI 23022.979 - Retinopathy of Prematurity- Stage V - 12/03/2012
Batch run: 12/03/2012
Rev:12/03/2012