Program Operations Manual System (POMS)
TN 33 (08-20)
DI 23022.979 Retinopathy of Prematurity - Stage V, Bilateral
COMPASSIONATE ALLOWANCES INFORMATION
|
RETINOPATHY OF PREMATURITY - STAGE V, BILATERAL
|
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/ICD-10-CM
CODING
|
Diagnostic testing: Complete ophthalmologic eye examination, including the diagnostic retinal staging
of ROP with total retinal detachment.
Physical
findings: Symptoms of ROP include:
-
•
Scarring and/or dragging of the retina;
-
-
•
Bleeding inside the eye (vitreous hemorrhage); and
-
ICD-9:
362.27
ICD-10: H35.109
|
PROGRESSION
|
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; and
-
•
Pediatric ophthalmological examination indicating total retinal detachment.
|
Suggested Listings for Evaluation:
|
DETERMINATION
|
LISTING
|
REMARKS
|
Meets
|
102.02 A or B
|
Findings must be bilateral. |
102.03 A or B or C
|
Findings must be bilateral. |
102.04 A or B
|
Findings must be bilateral. |
Equals
|
|
|
* Adjudicators may, at their discretion, use the Medical Evidence of Record or the
listings suggested to evaluate the claim. However, the decision to allow or deny the
claim rests with the adjudicator.
|