Local Coverage Determination (LCD)

Panretinal (Scatter) Laser Photocoagulation

L33628

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33628
Original ICD-9 LCD ID
Not Applicable
LCD Title
Panretinal (Scatter) Laser Photocoagulation
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/19/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Panretinal laser photocoagulation (PRP) involves extensive treatment with an argon or diode laser to the peripheral and middle portions of the retina. Photocoagulation is designed to burn and seal unwanted blood vessels, thus preventing hemorrhage. Panretinal laser photocoagulation targets the ablation of ischemic retina which in turn reduces the production of various cytokines, such as vascular endothelial growth factor (VEGF), thereby causing regression of neovascularization. Panretinal photocoagulation may also be used to ablate small areas of neovascularization on the retina. The initial treatment usually consists of approximately 1500-2000 spots of laser per eye. This is accomplished in two or more sessions. This local coverage determination (LCD) documents the indications and limitations of coverage for use of panretinal laser photocoagulation.

Indications:

Panretinal laser photocoagulation is indicated for the treatment or management of patients with proliferative or pre-proliferative diabetic retinopathy and patients with severe levels of diabetic macular edema associated with pre-proliferative retinopathy, and other proliferative retinopathies.

While panretinal laser photocoagulation greatly reduces the risk of visual loss in all states of proliferative retinopathy, treatment is withheld until the risk of visual loss outweighs the risks and side effects of the treatment.

Limitations:

Medicare coverage of panretinal laser photocoagulation using a laser is limited to management of proliferative or pre-proliferative retinopathies.


Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

American Academy of Ophthalmology. Diabetic retinopathy, preferred practice pattern. San Francisco; American Academy of Ophthalmology, 2003.

Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. 2007;298(8):902-916.

National Government Services, Inc. and other Medicare contractor's local coverage determinations.

Ophthalmology, 2nd ed. Mosby; 2004.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/19/2019 R11

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R10

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56550. There has been no change in coverage with this LCD revision.

 

  • Provider Education/Guidance
01/01/2018 R9

Added ICD-10-CM diagnosis code ranges H40.51X1-H40.51X4; H40.52X1-H40.52X4; H40.53X1-H40.53X4 should be reported with the ICD-10-CM diagnosis code reflecting the underlying condition, effective for services rendered on or after January 1, 2018.

 

  • Provider Education/Guidance
10/01/2016 R8 Added the following ICD-10-CM codes to the ICD-10 Codes that Support Medical Necessity section due to the annual ICD-10-CM update, effective for services rendered on or after 10/1/2016: E08.3291, E08.3292, E08.3293, E08.3391,
E08.3392, E08.3393, E08.3491, E083492, E08.3493, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533,
E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E09.3531, E09.3532,
E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E10.3411, E10.3412, E10.3413, E10.3521,
E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553,
E11.3391, E11.3392, E11.3393, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542,
E11.3543, E11.3551, E11.3552, E11.3553, E13.3291, E13.3292, E13.3293, E13.3391, E13.3392, E13.3393, E13.3491,
E13.3492, E13.3493, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543,
E13.3551, E13.3552, E13.3553, H35.011, H35.012, H35.013, H35.031, H35.032, H35.033, H35.071, H35.072,
H35.073, H35.101, H35.102, H35.103, H35.111, H35.112, H35.113, H35.121, H35.122, H35.123.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R7 Added the following ICD-10-CM diagnosis code ranges to the ICD-10 Codes that Support Medical Necessity section: E10.3511-E10.3513, E10.3591-E10.3593, E11.3511-E11.3513, E11.3591-E11.3593, E13.3511-E13.3513, and E13.3591-
E13.3593, effective for services rendered on or after 10/1/2016.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R6 Added multiple 2017 ICD-10-CM codes to the ICD-10 Codes that Support Medical Necessity section due to the annual ICD-10-CM update.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R5 Deleted "or xenon arc" under Limitations of coverage section because the technology is clinically outdated.
  • Provider Education/Guidance
  • Request for Coverage by a Practitioner (Part B)
01/01/2016 R4 Deleted the following utilization guideline: "CPT code 67228 should only be reported and paid once per 90-day global period per eye no matter how many treatment sessions occur.", effective for services rendered on or after 1/1/2016.
  • Provider Education/Guidance
01/01/2016 R3 Added ICD-10-CM diagnosis code ranges H35.131-H35.133 and H35.141-H35.143
to Group 1, effective for services rendered on or after 10/01/2015.
  • Request for Coverage by a Practitioner (Part B)
01/01/2016 R2 Based on 2016 HCPS updates, the description was changed for CPT code 67228.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R1 LCD updated to reflect administrative changes.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/11/2019 09/19/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • laser
  • laser photocoagulation
  • eyes
  • laser for diabetes
  • retinopathy

Read the LCD Disclaimer