Indications and Limitations of Coverage and/or Medical back to top

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1 Fr services perfrmed n r after 09/15/2009 Original Determinatin Ending Date Revisin Effective Date Revisin Ending Date Indicatins and Limitatins f Cverage and/r Medical Necessity Indicatins Medicare cverage fr cataract extractin and cataract extractin with intracular lens implant is based n services that are reasnable and medically necessary fr the treatment f beneficiaries wh have a cataract, and wh meet the fllwing criteria: 1. The patient has undergne a standardized frmal measure f his visual functinal status, the results f which suggest that the patient's visual functinal status can be imprved cmmensurate with the risk f surgery by underging cataract extractin with intracular lens implant. Such testing can be perfrmed with standardized measurement tls. 2. The patient has impairment f visual functin due t cataract(s) resulting in: Decreased ability t carry ut activities f daily living such as reading, viewing televisin, driving r meeting ccupatinal r vcatinal expectatins. Snellen visual acuity f 20/40 r wrse. If there is a glare cmpnent, glare testing which reduces visual acuity t wrse than 20/40. Special situatins might arise where a patient wuld need

2 better than 20/40 visin t functin (pilts, prfessinal drivers, etc.). In these instances additinal dcumentatin shuld be available in the patient's medical recrd describing these circumstances.(see belw under Dcumentatin) 3. Other medical indicatins exist fr cataract remval such as: Clinically significant anismetrpia in the presence f a cataract. The lens pacity interferes with ptimal diagnsis r management f psterir segment cnditins. The lens causes inflammatin (phaclysis, phacanaphylaxis). The lens induces angle clsure (phacmrphic, phactpic). 4. The patient has undergne an apprpriate preperative phthalmlgic evaluatin, which generally includes a cmprehensive phthalmlgic exam and either: an A-scan ultrasund, r partial cherence interfermetry with either keratmetry r crneal tpgraphy. Other phthalmlgic studies shuld be reserved fr special situatins, such as: B-scan fr patients with dense cataracts, which preclude visualizatin f the psterir segment f the eye including the vitreus and/r retina, but nt limited t these. Preperative Ophthalmlgic Evaluatin and Testing Rutine pre-perative phthalmlgic screening withut substantiated signs r symptms f disease is nt medically necessary. Where the nly diagnsis is cataract(s), Medicare des nt cver testing ther than ne preperative phthalmlgic evaluatin, which generally includes a cmprehensive phthalmlgic examinatin and an A-scan ultrasund r OCB

3 (when an IOL is planned). The gals f the physical examinatin f a patient whse chief cmplaint may be related t a cataract are: t diagnse r cnfirm the presence f a cataract t cnfirm that the cataract is a significant factr related t the visual impairment and symptms described by the patient t exclude r identify ther cular r systemic cnditins that might cntribute t the patient s visual impairment r affect the surgical plan r ultimate utcme. The phthalmic examinatin shuld include the fllwing cmpnents: 1. Patient histry (including patient s assessment f functinal status 2. Snellen acuity and refractin 3. Measurement f intracular pressure 4. Assessment f pupillary functin 5. Examinatin f cular mtility 6. External examinatin 7. Slit-lamp examinatin 8. Dilated examinatin f the fundus (unless cntraindicated by the anatmy f the eye) The fllwing tests are generally nt indicated in the preperative wrkup fr cataract surgery. If perfrmed, the indicatins fr their use must be dcumented in the patient s medical recrd: Cntrast sensitivity testing. Ptential visin testing. Frmal visual fields. Flurescein angigraphy. External phtgraphy. Crneal pachymetry/specular micrscpy. Specialized clr visin tests. Electrphysilgic tests. The maximum interval between the preperative examinatin and the date f surgery shuld be n greater than 3 mnths. Patients shuld be educated t cntact the phthalmlgist if they have a

4 change in visual symptms during the interval between the preperative examinatin and the surgery. Cntraindicatins The fllwing are cntraindicatins t surgery fr visually impairing cataract except as nted abve: Glasses r visual aids prvide satisfactry functinal visin. The patient s lifestyle is nt cmprmised by the cataract. The patient is unable t underg surgery because f cexisting medical r cular cnditins. The patient des nt desire surgery. Surgery will nt imprve visual functin. A legal cnsent cannt be btained. Limitatins All f the patient selectin criteria utlined in the Indicatins and Limitatins f Cverage and/r Medical Necessity sectin f this plicy have nt been met (e.g., best crrected visual acuity f less than 20/40). Preperative testing perfrmed in excess f the guidelines utlined in the Indicatins and Limitatins Cverage and/r Medical Necessity sectin f this plicy will be cnsidered nt medically necessary. It is expected that mre than ne A-scan r OCB per year wuld generally nt be medically necessary. Ophthalmic bimetry fr lens pwer calculatin shuld nt be perfrmed unless a decisin t remve the cataract has been made by the patient and the surgen. If the bimetry is perfrmed by an ptmetrist, he/she shuld d s in crdinatin with the perating surgen s that nly ne prcedure is necessary. If bimetry is repeated by the perating surgen due t the inadequacy f the study, the riginal eye care physician/prvider shuld anticipate nt being reimbursed fr the study. B-scans perfrmed withut dcumented evidence f a dense

5 cataract r that the cataract precluded visualizatin f the psterir segment f the eye including the vitreus and/r retina will be cnsidered nt medically necessary. Secnd-eye Surgery: The fllwing is taken frm Cataract in the Adult Eye published as a Preferred Practice Pattern by the American Academy f Ophthalmlgy: Surgery shuld nt be perfrmed in bth eyes at the same time because f the ptential fr bilateral visual lss. Cnsideratin f the apprpriate interval between the first-eye surgery and secnd-eye surgery is influenced by several factrs: the patient's visual needs, the patient's preferences, visual acuity r functin in the secnd eye, the medical and refractive stability f the first eye, the need t develp bincular visin and symptmatic anismetrpia as well as lgistical cncerns f the patient in traveling back and frth t the physician's ffice. The patient and the phthalmlgist shuld discuss the benefit, risk and timing f secnd-eye surgery when they have had the pprtunity t evaluate the results f surgery n the first eye. Prir t perfrming surgery n the secnd eye, the patient's first eye shuld have a stable pstperative refractin and the patient shuld perceive imprved functin, and sufficient time shuld have elapsed t evaluate and treat early pstperative cmplicatins, such as endphthalmitis. The patient needs sufficient time t assess the results f his r her first-eye surgery t determine the need and apprpriate timing fr surgery in the secnd eye. Cverage Tpic Diagnstic Tests and X-Rays Dctr Office Visits Outpatient Hspital Services Surgical Services

6 Cding Infrmatin Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 999x Nt Applicable Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue

7 Cding Infrmatin Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. CPT/HCPCS Cdes REMOVAL OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID) WITH CORNEO-SCLERAL SECTION, WITH OR WITHOUT IRIDECTOMY (IRIDOCAPSULOTOMY, IRIDOCAPSULECTOMY) REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY REMOVAL OF LENS MATERIAL; INTRACAPSULAR REMOVAL OF LENS MATERIAL; INTRACAPSULAR, FOR DISLOCATED LENS REMOVAL OF LENS MATERIAL; EXTRACAPSULAR (OTHER THAN 66840, 66850, 66852) EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE INTRACAPSULAR CATARACT EXTRACTION WITH

8 Cding Infrmatin INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE) EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) ICD-9 Cdes that Supprt Medical Necessity It is the prvider s respnsibility t select cdes carried ut t the highest level f specificity and selected frm the ICD-9-CM cde bk apprpriate t the year in which the service is rendered fr the claim(s) submitted NONSENILE CATARACT UNSPECIFIED - UNSPECIFIED CATARACT Diagnses that Supprt Medical Necessity N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity All thse nt listed under the ICD-9 Cdes that Supprt Medical Necessity sectin f this plicy. ICD-9 Cdes that DO NOT Supprt Medical Necessity Asterisk Explanatin Diagnses that DO NOT Supprt Medical Necessity Cnditins that are nt listed in the "ICD-9-CM Cdes that Supprt Medical Necessity" sectin f this plicy.

9 General Infrmatin Dcumentatin Requirements 1. All dcumentatin must be maintained in the patient s medical recrd and available t the cntractr upn request. 2. Every page f the recrd must be legible and include apprpriate patient identificatin infrmatin (e.g., cmplete name dates f service(s)). The recrd must include the physician r nn-physician practitiner respnsible fr and prviding the care f the patient. Dcumentatin supprting medical necessity (e.g., ffice/prgress ntes) f the cataract surgery must cntain: - Visual acuity (best crrected Snellen chart); - Symptmatlgy; - The use f cnservative treatment including current refractin is n lnger satisfactry; - Degree f functinal impairment (This can be in any frm; e.g., narrative r assessment tl as lng as it supprts hw the cataract affects the patient s ADLs.)

10 General Infrmatin 3. The submitted medical recrd shuld supprt the use f the selected ICD-9-CM cde(s). The submitted CPT/HCPCS cde shuld describe the service perfrmed.