Cataract Extraction (including Complex Cataract Surgery)

Jurisdiction: J9 MAC Part B. States: Florida, Puerto Rico, US Virgin Islands. Type: Active LCD

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Cataracts occur frequently as a progressive, age-related disease that is the leading cause of blindness in the U.S. and accounts for 50% of visual impairment over the age of 40. Cataracts are the leading cause of treatable blindness among African Americans age 40 and older. As part of the aging process, the lens increases in thickness and weight causing hardening and compression on the nucleus eventually developing a yellow-brown color that changes the transparency of the lens. Cataracts have several different types that have their own anatomical location, pathology, and risk factors (e.g., nuclear, cortical, subcapsular [anterior and posterior], and mixed). Cataracts can lead to blurred or distorted vision, glare problems, color vision defects, and a decline of contrast sensitivity and depth perception. These impairments lead to loss of balance, less independent mobility, falls, injuries, increased mortality risk, and decreased mental well-being. This raises more concern for the elderly population due to underlying systemic comorbidities. Visual function plays a major role in physical performance, mental well-being, and mobility for the elderly. 1 Risk factors for cataracts include diabetes mellitus, family history, hypertension, ionizing radiation, myopia, obesity, smoking, ultraviolet-B light exposure, long-term topical, systemic, or oral corticosteroid use, prior intraocular surgery, and lower level education. Improving visual function and quality of life have increased the demand for cataract surgery. Since there are no pharmacologic treatments to eliminate cataracts, cataract surgery is the primary management of significant visual impairment. 1 Due to the different types of cataracts, the decision-making process for cataract surgery can be complex in determining the appropriate treatment, technique, devices, and complications to consider. Symptomatic cataract is a surgical disease and the standard of care in cataract surgery in the U.S. is a small-incision phacoemulsification with foldable intraocular lens (IOL) implantation. 1 In consideration for cataract surgery, cataract patients must have an impairment of visual function due to cataract(s) resulting in the decreased ability to carry out activities of daily living such as reading, viewing television, driving or meeting occupational or vocational expectations. This LCD provides medically reasonable and necessary indications for both routine and complex cataract surgery. Coverage will be based upon documentation that supports medical necessity and therefore covered by Medicare when one or more of the covered indications are present. Covered Indications Cataract Surgery will be considered medically reasonable and necessary when one or more of the following indications are present: Visual function no longer meets the patient’s needs based on visual acuity, visual impairment, and potential for functional benefits. 2 Visual Impairment and function are not correctable by glasses or other non-surgical measures. 3 The patient has undergone a preoperative examination that documents the following: Inability to function satisfactorily due to visual impairment while performing various Activities of Daily Living. 1,2 Confirmation that cataract is causing the visual impairment or other ocular or systemic conditions. 1 Cataract is causing unacceptable glare, polyopia, or reduced quality of vision. 1-3 There is clinically significant anisometropia in the presence of a cataract. 1,2 The lens opacity interferes with optimal diagnosis or management of posterior segment conditions. 1,2 The lens causes inflammation or secondary glaucoma (phacolysis, phaco-anaphylaxis). 1,2 There is worsening angle closure (phacomorphic glaucoma) due to increase in size of the crystalline lens. 1,2 A significant cataract is present in a patient who will be undergoing concurrent surgery in the same eye, such as a trabeculectomy or a corneal transplant when the surgeon deems that the decreased morbidity of single stage surgery is of significant benefit over surgery on separate dates. 1,2 Please refer to NCD 10.1-Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery for information on pre surgery evaluations. Complex cataract surgery : Indications: Complex cataract surgery will be considered medically reasonable and necessary when there is one of the following: A miotic pupil that will not dilate sufficiently 4 requirng the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye. 4 Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens. 5 Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis. Mature cataract requiring dye for visualization of capsulorrhexis. Refer to CMS IOM Pub. 100-04, Medicare Claims Processing Manual , Chapter 32, Section 120, for CMS guidelines on IOL insertion benefit following cataract surgery. Limitations The following are considered contraindicators to surgery for visually impairing cataract and are not considered medically reasonable and necessary: Tolerable refractive correction that provides vision and meets the patient’s needs and desires. 2 The patient’s lifestyle is not compromised by the cataract and they are able to perform activities of daily living. 1,2 The patient cannot safely undergo surgery because of coexisting medical or ocular conditions. 1,2 Surgery is not expected to improve visual function, or no other indication for lens removal exists. 1,2 Provider Qualifications Services will be considered medically reasonable and necessary when all aspects of care are within the scope of practice of the provider’s professional licensure, when performed according to the supervision requirements per state scope of practice laws, and when all procedures are performed by appropriately trained providers in the appropriate setting. Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.