Local Coverage Article Response to Comments

Response to Comments: Cataract Extraction


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Response to Comments: Cataract Extraction
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Response to Comments
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As an important part of Medicare Local Coverage Determination (LCD) development, National Government Services solicits comments from the provider community and from members of the public who may be affected by or interested in our LCDs. The purpose of the advice and comment process is to gain the expertise and experience of those commenting.

National Government Services thanks those who reviewed our draft LCD on Cataract Extraction during the June 30, 2016 through August 13, 2016 Comment Period. The Notice Period began on September 16, 2016, and will end on October 31, 2016. The final LCD will become effective for services rendered on or after November 1, 2016.

Response To Comments

1We received essentially identical recommendations from NGS CAC representatives and the American Academy of Ophthalmology (AAO), recommending eliminating a specific visual acuity threshold, citing other MAC policies and the American Academy of Ophthalmology Preferred Practice Pattern on Cataract Surgery (2011): “The decision to recommend cataract surgery should be based on consideration of the following factors: visual acuity, visual impairment, and potential for functional benefits. (strong recommendation, good evidence). There is no single test or measure that adequately describes the effect of a cataract on a patient's visual status or functional ability. Therefore, no single test can properly define the threshold for performing cataract surgery. Though various methods of acuity measurement have long been considered the primary determinant for surgical appropriateness, the decision to recommend cataract surgery should not be made solely on this basis. For example, surgery for nonadvanced cataract in symptomatic patients with relatively good Snellen visual acuity often provides significant functional benefits. Standardized evaluation of impairment of visual function and activities of daily living has been shown to correlate with expected improvement and satisfaction after cataract surgery. Several of these validated testing instruments and recent modifications are available for clinical use.” NGS agrees and has modified the section accordingly. We’ve also adopted some of the indications in the Noridian LCD as also recommended.
2With regard to the LCD on cataract surgery I would request that NGS change the language in the first bullet point from “or meeting occupational or vocational expectations”, which is redundant, to: “or meeting occupational or avocational expectations”, since we are talking about those over 65 years of age, most of whom are retired and not engaged in occupational work as much as hobbies and other non-work related activities. NGS agrees and the modification associated with comment #1 addressed this as well.
3We received a comment from Allina Health and Phillips Eye Institute recommending several specific additions to the existing bullets defining when the 20/50 visual acuity requirement would not apply. NGS agrees with the intent of these recommendations and feels they have been addressed by the revisions associated with comment #1.
4With regard to immediate, sequential bilateral cataract surgery, this is clearly a risk benefit analysis that should be considered very seriously in light of the potential for disastrous, bilateral blinding disease. For most patients, the opportunity to plan the second operation after seeing the results from the first makes all of us better surgeons. I believe the indications they list are reasonable. Five years from now economic considerations may dictate otherwise!Thank you
5We received the following comment: “The definition of complex cataract surgery no longer includes “dye”. See CPT Assistant – March 2016. Remove the sentence that says “the operative note indicates dye was used to stain the anterior capsule.” NGS disagrees. While not all complex cataract surgery involves dye (hence its appropriate removal from the CPT definition), surgery that involves dye is generally complex.
6In reviewing the terminology for Code 66982, Complex cataract, the wording for “endocapsular ring to partially occlude the pupil” does not sound correct. Was the reference supposed to be for endocapsular iris segment to revise a deformed pupil? This should be clarified. NGS agrees and has modified the section accordingly.

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