TL;DR: Aetna, a CVS Health company, modified CPB 0854 governing electroretinography coverage, effective January 5, 2026. Billing teams need to confirm indication-specific coverage before submitting CPT 92273, 92274, or 0509T claims.
Aetna's electroretinography coverage policy under CPB 0854 in the Aetna system draws sharp lines between covered and non-covered indications — and the list of experimental designations is long. The policy covers CPT 92273 (full-field ERG) and CPT 92274 (multifocal ERG) for a specific set of diagnoses. CPT 0509T (pattern ERG) gets no coverage at all. If your practice bills ERG for anything outside the approved indications, expect a claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Electroretinography — CPB 0854 |
| Policy Code | CPB 0854 |
| Change Type | Modified |
| Effective Date | January 5, 2026 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Retinal Surgery, Neurology, Rheumatology |
| Key Action | Audit all ERG claims against the approved indication list before billing CPT 92273, 92274, or 0509T |
Aetna Electroretinography Coverage Criteria and Medical Necessity Requirements 2026
The Aetna electroretinography coverage policy under CPB 0854 covers ERG only when you can show a clear, approved clinical indication. Medical necessity is indication-specific — not procedure-specific. The test itself doesn't get coverage; the reason you're running it does.
Here's what Aetna considers medically necessary as of January 5, 2026:
Full-field ERG (CPT 92273) is covered for congenital stationary night blindness diagnosis, evaluation of Vogt-Koyanagi-Harada disease, and evaluation of exudative retinal detachment. It's also covered adjunctively to distinguish retinal from optic nerve lesions, and as part of a congenital nystagmus work-up.
Multifocal ERG (CPT 92274) is covered to detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity — a critical use case for rheumatology patients on long-term antimalarial therapy. Both CPT 92273 and CPT 92274 are covered for evaluating Stargardt disease in children.
The policy does not list explicit prior authorization requirements in its medical necessity criteria. That said, with this many experimental exclusions on the list, your team should verify prior auth requirements with Aetna directly before scheduling ERG for any non-routine indication. A quick auth check now is cheaper than an appeal later.
Medical necessity documentation needs to match one of these approved indications precisely. Vague documentation — "retinal evaluation" or "vision loss work-up" — won't hold up on audit. Your ICD-10 codes need to tell the story.
Aetna Electroretinography Exclusions and Non-Covered Indications
This is where the policy gets complex — and where your denial risk is highest. The experimental, investigational, or unproven list is extensive. The clinical community has pushed ERG into a wide range of applications. Aetna isn't buying most of them yet.
CPT 0509T (pattern ERG) is not covered for any indication under this policy. Full stop. That code goes on your "bill only if you're ready for a denial" list for Aetna patients.
CPT 92273 (full-field ERG) is experimental for two specific uses: monitoring during endoscopic trans-sphenoidal pituitary mass resection (CPT 62165 is a related code Aetna flags) and evaluation of refractive errors including astigmatism, hyperopia, myopia, and presbyopia. If a surgeon asks your team to bill ERG monitoring during a pituitary resection, that's a non-covered service under this policy.
For CPT 92274 (multifocal ERG), Aetna considers it experimental for idiopathic epiretinal membrane, multiple evanescent white dot syndrome, poppers maculopathy, and prediction of visual acuity decline in age-related macular degeneration.
The biggest flag in this policy is the psychiatric and neurological exclusion list. Aetna explicitly calls out ERG as experimental for anti-depressant selection, diagnosis of major depressive disorder, ADHD, eating disorders, panic disorder, schizophrenia, substance use disorder, and suicidal ideation. These are real billing patterns — labs and some psychiatric practices have pushed ERG for these indications. Aetna is drawing a hard line.
Also experimental: ERG for autism spectrum disorder evaluation, diagnosis of glaucoma, differentiation of hypersomnia subtypes, evaluation of childhood brain tumor survivors, evaluation of rhegmatogenous retinal detachment, and use as a diagnostic biomarker for acute retinal necrosis.
Screening for chloroquine and hydroxychloroquine retinopathy also shows up on the experimental list — but read this carefully alongside the covered indications. Aetna covers CPT 92274 to detect toxicity in confirmed cases. Routine screening in asymptomatic patients is a different clinical question, and the policy calls that experimental. Your documentation needs to reflect active monitoring for toxicity, not preventive screening.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Congenital nystagmus work-up | Covered | CPT 92273, 92274 | Adjunctive use |
| Distinguishing retinal vs. optic nerve lesions | Covered | CPT 92273, 92274 | Adjunctive modality |
| Chloroquine / hydroxychloroquine toxicity detection | Covered | CPT 92274 | Detection, not screening |
| Congenital stationary night blindness | Covered | CPT 92273 | Diagnosis |
| Vogt-Koyanagi-Harada disease | Covered | CPT 92273 | Evaluation |
| Exudative retinal detachment | Covered | CPT 92273 | Evaluation |
| Stargardt disease in children | Covered | CPT 92273, 92274 | Pediatric patients |
| Pituitary mass resection monitoring | Experimental | CPT 92273 | Related: CPT 62165 |
| Refractive error evaluation (myopia, astigmatism, etc.) | Experimental | CPT 92273 | Not covered |
| Glaucoma diagnosis/evaluation | Experimental | CPT 92273, 92274, 0509T | All ERG types |
| Idiopathic epiretinal membrane | Experimental | CPT 92274 | Not covered |
| Multiple evanescent white dot syndrome | Experimental | CPT 92274 | Not covered |
| Poppers maculopathy | Experimental | CPT 92274 | Not covered |
| AMD visual acuity decline prediction | Experimental | CPT 92274 | Not covered |
| Pattern ERG for any indication | Not Covered | CPT 0509T | No covered indications |
| Psychiatric disorder diagnosis (ADHD, MDD, schizophrenia, etc.) | Experimental | Any ERG code | Explicit exclusion list |
| Suicidal ideation diagnosis | Experimental | Any ERG code | Explicitly excluded |
| Autism spectrum disorder evaluation | Experimental | Any ERG code | Not covered |
| Rhegmatogenous retinal detachment | Experimental | Any ERG code | Not covered |
| Acute retinal necrosis biomarker | Experimental | Any ERG code | Not covered |
| Hypersomnia subtype differentiation | Experimental | Any ERG code | Not covered |
| Childhood brain tumor survivor evaluation | Experimental | Any ERG code | Not covered |
| Hydroxychloroquine retinopathy screening | Experimental | Any ERG code | Screening ≠ detection |
Aetna Electroretinography Billing Guidelines and Action Items 2026
The effective date is January 5, 2026. If you haven't already aligned your charge capture to this policy, do it now.
| # | Action Item |
|---|---|
| 1 | Remove CPT 0509T from your Aetna charge capture. Pattern ERG has no covered indications under this policy. Any CPT 0509T claim against an Aetna plan will deny. Flag it in your billing system so it routes to a patient responsibility conversation before the service happens. |
| 2 | Build a hard stop for psychiatric ERG indications. If your practice gets ERG orders tied to depression, ADHD, schizophrenia, or any other psychiatric diagnosis, those claims will not clear Aetna. Talk to your scheduling team and your ordering providers now. This is a documentation and order entry problem as much as a billing one. |
| 3 | Separate "toxicity detection" from "screening" in your hydroxychloroquine documentation. Aetna covers CPT 92274 for detecting active toxicity. It calls routine screening experimental. Your encounter notes and ICD-10 codes need to reflect active toxicity monitoring — not preventive or baseline screening. Work with your clinical team to get the language right before the claim goes out. |
| 4 | Audit open and pending ERG claims against the approved indication list. Pull any Aetna ERG claims filed or pending after January 5, 2026. Cross-reference the diagnosis codes against the covered indications above. Claims billed under experimental indications will deny. Better to catch mismatches before Aetna does. |
| 5 | Verify prior auth requirements before scheduling ERG for complex cases. The policy doesn't mandate prior authorization in the written criteria, but Aetna plan designs vary. Pediatric Stargardt cases, Vogt-Koyanagi-Harada evaluations, and multi-indication work-ups are complex enough that a pre-service authorization check protects your reimbursement. Call Aetna provider services or check the portal for the specific plan. |
| 6 | Train your coders on the screening vs. detection distinction. This is the subtlest trap in the policy. The ICD-10 codes tied to chloroquine and hydroxychloroquine toxicity monitoring span a wide range of diagnosis codes — get your coders aligned on which codes signal active toxicity monitoring versus routine drug surveillance. If you're unsure how to map this for your patient mix, loop in your compliance officer before you file. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Electroretinography Under CPB 0854
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 92273 | CPT | Electroretinography (ERG), with interpretation and report; full field (ffERG, flash ERG, Ganzfeld) |
| 92274 | CPT | Electroretinography (ERG), with interpretation and report; multifocal (mfERG) |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0509T | CPT | Electroretinography (ERG) with interpretation and report, pattern (PERG) | Not covered for any indication |
Key ICD-10-CM Diagnosis Codes
The policy maps to 705 ICD-10-CM codes. The codes below represent the major diagnostic categories relevant to covered indications. Your billing team should reference the full code list in the Aetna CPB 0854 policy document for complete mapping.
| Code | Description |
|---|---|
| B50.0–B54 | Malaria (relevant to chloroquine use and toxicity monitoring) |
| D18.09 | Hemangioma of other sites (retina) |
| E08.311 | Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy |
| E08.3211–E08.3219 | Diabetes mellitus with mild nonproliferative diabetic retinopathy |
| E08.3311–E08.3319 | Diabetes mellitus with moderate nonproliferative diabetic retinopathy |
| E08.3411–E08.3419 | Diabetes mellitus with severe nonproliferative diabetic retinopathy |
| E08.3511–E08.3549 | Diabetes mellitus with proliferative diabetic retinopathy |
The full 705-code ICD-10 list covers malaria diagnosis codes through extensive diabetic retinopathy subcategories. Confirm the complete applicable code set in the source policy at the Aetna CPB 0854 document before finalizing your charge capture mapping.
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