LCD Reference Article Response To Comments Article

Response to Comments: Cataract Extraction

A59621

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Article ID
A59621
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Article Title
Response to Comments: Cataract Extraction
Article Type
Response to Comments
Original Effective Date
02/11/2023
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This article summarizes the comments WPS received for Draft Local Coverage Determinations (LCD) Cataract Extraction DL39716. Thank you for the comments.

Response To Comments

Number Comment Response
1

The American Academy of Ophthalmology (the Academy) and the American Society of Cataract and Refractive Surgery (ASCRS) submitted comments sharing a concern that the requirement that “the patient has a best corrected Snellen visual acuity of 20/50 or worse at distance or near, and the cataract is responsible for the decreased activity”, could result in restricted patient access to sight-restoring eyecare. They state the visual acuity criterion is outdated, and that a significant number of cataract patients struggle with activities of daily living, despite having a best corrected Snellen visual acuity scores which are better than 20/50. High contrast visual acuity underestimates problems with vision performing activities of daily living such as driving, employment, and reading. Vision for such patients is functionally impaired by other symptoms not reflected in visual acuity measurements, such as glare, halos, and starburst.

The recently updated Academy’s Preferred Practice Pattern for Cataract in the Adult Eye (2021) states “Because preoperative distance visual acuity alone may be an unreliable predictor of postoperative functional improvement, the decision to recommend cataract surgery should not be made solely on the basis of Snellen visual acuity. Studies have indicated that measures of functional visual impairment provide valid and reliable information that is not reflected in the measurement of visual acuity alone.”

WPS agrees with the Academy and the ASCRS. The LCD has been updated to remove the coverage indication that the patient has a best corrected Snellen visual acuity of 20/50 or worse at distant or near, and the cataract is responsible for the decreased acuity

2

We received multiple comments from providers disagreeing with the coverage indication that the patient has a best corrected Snellen visual acuity of 20/50 or worse at distant or near, and the cataract is responsible for the decreased acuity. They cite concern that by the time patient’s reach a visual acuity of 20/50, they can no longer drive. Providers have commented concerns that patients with visual acuity better than 20/50 still may not be able to read, drive at night, or complete activities of daily living.

See Comment #1

3

Comments were received from an academic ophthalmologist with the University of Iowa. Their concern is that lack of verbiage in the proposed LCD regarding coverage for cataract extraction for purposes of mitigating angle closure glaucoma. They state in the available literature and their experience that cataract extraction seems to have only a modest and temporary alleviating effect on intraocular pressure, it is also well recognized in established literature as well as standard of care practice that cataract extraction is very beneficial and almost curative in some cases for angle closure and angle closure glaucoma. The commenter submitted 9 new references to support cataract extraction for angle closure glaucoma.

Thank you for submission of these studies which have been added to the LCD. We agree that there is evidence to support adding coverage for cataract extraction in patients with narrow angle glaucoma. The relevant diagnosis codes have been added to the associated Billing and Coding article.

The request to add clear lens extraction in the treatment of narrow angle glaucoma is beyond the scope of this LCD which is specific to cataract.

4

We received comment from a CAC member in writing and during the CAC meeting held on 10/26/23, with concerns regarding the requirement that the patient has a best corrected Snellen visual acuity of 20/50 or worse at distant or near, and the cataract is responsible for the decreased acuity. The CAC member states the Snellen Acuity only measures a portion of our vision. A very significant portion of our vision is contrast sensitivity. This is not measured on the Snellen Acuity chart. However, a significant reduction in contrast sensitivity that can be brought on by cataracts can be devastating for a patient’s quality of life. These patients may find that they can no longer drive at night. They may find that they can no longer read a book or newsprint. Yet, they may very well have better than 20/50 vision. They also state that every state in the USA denotes 20/40 vision as the minimum vision to maintain an unrestricted driver’s license. This LCD requirement would force patients to lose their drivers license prior to getting cataract surgery.

The provider also commented concern with the requirement that providers must prove that retinal disease is not the primary cause of vision loss in the patient. They state they have removed cataracts on patients with advanced macular degeneration, proliferative diabetic retinopathy, or retinal occlusions on many occasions. There is concern that under this requirement, a patient would not receive cataract extraction until the practioner could no longer see clearly into the back of the eye. The CAC member notes that patients they have treated with cataract extraction note significant improvement in their quality of vision, improvement in peripheral vision, fewer falls and reduced rates of dementia symptoms.

In response to the first comment, please see Comment #1.

In response to the second comment, there was no literature provided to support the commenters concern. However, we understand that cataract(s) often accompany associated ocular diseases that potentially affect visual function. We have updated the wording in the Coverage Indication section of our LCD to reflect this.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39716 - Cataract Extraction
Related National Coverage Documents
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SAD Process URL 2
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Updated On Effective Dates Status
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