About this policy
Jurisdiction: J8 MAC Part B. States: Indiana, Michigan. Type: Active LCD
Coverage indications
A cataract is a degradation of the optical quality of the crystalline lens that affects vision. Cataracts cause an opacity or cloudiness in the lens of the eye(s) which blocks the passage of light through the lens. 6 Cataracts occur frequently as a progressive age-related disease and is the leading cause of blindness worldwide of all ethnic and racial backgrouds. 6 More than half of all Americans age 80 or older either have cataracts or have had surgical treatment of cataracts. 2 Cataract is the leading cause of visual impairment among Americans of all studied ethnic and racial backgrounds. 3 The number of people in the United States with cataracts is expected to double from 24.4 million to approximately 50 million in the next 30 years. 2,6 Most cataract development is related to aging, and it can occur in one or both eyes. 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 which increases with each decade of life starting around age 40. 6 Risk factors that can increase cataract development may include smoking, ultraviolet β radiation exposure, complications of diabetes, and drug and/or alcohol use. 2 Medicare coverage for cataract extraction, and cataract extraction with intraocular lens implant, is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This policy defines coverage and describes criteria necessary to justify the performance of cataract surgery. Coverage Indications In the clinical presence of cataract(s), cataract surgery is considered medically necessary when the following conditions or circumstances exists, and are clearly documented in the medical record: After comprehensive medical eye evaluation 6 AND Consideration of the risk factors for undergoing the planned anesthesia, 6 AND Informed consent from the patient or the patient’s health care power of attorney after discussing the risks, benefits, and expected outcomes of surgery, including the anticipated refractive outcome, 6 AND Outcome measures of cataract surgery such as visual acuity, accuracy of refractive correction, occurrence of significant operative and postoperative complications shall be recorded post-operatively, 4,6 AND The cataract is causing visual impairment that is not correctable with a tolerable change in glasses or contact lenses, resulting in the inability to perform Activities of Daily Living such as, but not limited to, driving, reading, watching television, and/or meeting vocational or recreational needs, 4 OR The lens opacity interferes with optimal diagnosis or management of posterior segment conditions (e.g., diabetic retinopathy or macular degeneration), 6 OR As a treatment of vision threatening cataract induced complications (e.g, the lens induces or risks angle closure , uveitis, dislocation of the lens), 6 OR During vitrectomy procedures, the lens interferes with the performance of vitreoretinal surgery, as in the case of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy, 6 OR There is a high probability of accelerating cataract development because of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation, 6 OR There is clinically significant anisometropia or aniseikonia that exists because of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity), 6 OR There is lens injury with potential lens swelling (traumatic cataract) 6 Please refer to NCD 10.1-Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery for information on pre surgery evaluations. Coverage Limitations Cataract surgery is not reasonable and necessary when all the above criteria are not fulfilled. AND Cataract surgery can only be performed once for the same eye. 6 Complex cataract surgery Coverage 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 requiring 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, 14 OR Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens, 15 OR 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, 6 OR Mature cataract requiring dye for visualization of capsulorrhexis. 6 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.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.