TN 22 (12-18)

DI 23022.979 Retinopathy of Prematurity - Stage V

COMPASSIONATE ALLOWANCE 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 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;

• Retinal detachment;

• Bleeding inside the eye (vitreous hemorrhage); and

• Blindness.

ICD-9: 362.27

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.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022979
DI 23022.979 - Retinopathy of Prematurity - Stage V - 12/28/2018
Batch run: 12/28/2018
Rev:12/28/2018