Local Coverage Determination (LCD)

Cataract Surgery in Adults


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
Original ICD-9 LCD ID
Not Applicable
LCD Title
Cataract Surgery in Adults
Proposed LCD in Comment Period
Source Proposed LCD
Original Effective Date
For services performed on or after 10/10/2017
Revision Effective Date
For services performed on or after 07/30/2023
Revision Ending Date
Retirement Date
Notice Period Start Date
Notice Period End Date
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 © 2024, 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 Description

Updated information. 

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act §1862(a)(7) excludes routine physical examinations.

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverage

Code of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical procedures

CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80.10, Phaco-Emulsification Procedure-Cataract Extraction

CMS Manual System, Pub 100-04, Medicare Claims Processing Manual Chapter 12, §§40.6, 40.7, Claims for Multiple Surgeries, Claims for Bilateral Surgeries

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Cataract is defined as an opacity or loss of optical clarity of the crystalline lens. Cataract development follows a continuum extending from minimal changes in the crystalline lens to the extreme stage of total opacity. Cataracts may be due to a variety of causes. Age-related cataract (senile cataract) is the most common type found in adults. Other types are pediatric (both congenital and acquired), traumatic, toxic and secondary (meaning the result of another disease process) cataract.

Most cataracts are not visible to the naked eye until they become dense enough (mature or hypermature) to cause blindness. However, a cataract at any stage of development can be observed through a sufficiently dilated pupil using a slit lamp biomicroscope. In settings where this instrument is unavailable (e.g., skilled nursing facility), a direct ophthalmoscope can be used to assess the degree to which the fundus reflectivity (red reflex) is impaired by the ocular media. There is no scientifically proven medical (i.e., non-surgical) treatment for cataracts.

In general, cataract surgery is performed to alleviate compromise of visual function attributable to lens opacity. There are uncommon situations when lens extraction becomes medically necessary for anatomic rather than optical reasons. These include lens induced angle closure (e.g., microspherophakia) and lens subluxation (e.g., Marfan syndrome). In other situations, cataract extraction might be medically indicated with relatively less opacity because of intolerable optical imbalance. Most commonly, this would be due to surgically induced anisometropia (a significant difference in refractive errors between the eyes) or aniseikonia (a difference in magnification as a result of prior lens extraction in the one eye). Some patients may elect lens removal and replacement primarily for refractive benefits to reduce their dependence on spectacles. Such elective procedures are not medically necessary and are called “refractive lens exchanges” to distinguish them from medically indicated cataract surgery. Finally, advanced cataracts may need to be removed to properly visualize, treat, and monitor retinal disease, apart from the patient’s visual symptoms and potential.

This policy statement defines the medical necessity for cataract and other lens extraction in adults, and specifies the required documentation of the preoperative evaluation necessary to justify the procedure.

Lens extraction is considered medically necessary and therefore covered by Medicare when one (or more) of the following conditions or circumstances are documented in the medical record (see Documentation Requirements in Article A57196):

  1. Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs.
  2. Concomitant intraocular disease (e.g., diabetic retinopathy or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract.
  3. Lens-induced disease threatening vision or ocular health (including, but not limited to, phacomorphic or phacolytic glaucoma).
  4. High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation.
  5. Cataract interfering with the performance of vitreoretinal surgery.
  6. Intolerable anisometropia or aniseikonia uncorrectable with glasses or contact lenses that exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity.

Any circumstances not listed may be considered based on the standard of care and other factors related to medical necessity at redetermination.

Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of one or more of the aforementioned justifications.

Visual Acuity
The Snellen visual acuity chart is an excellent way of measuring distance refractive error (e.g. myopia, hyperopia, astigmatism) in healthy eyes, and is in wide clinical use. However, testing only with high contrast letters viewed in dark room conditions will underestimate the functional impairments caused by some cataracts in common real-life situations such as day or nighttime glare conditions, poor contrast environments or reading, halos and starbursts at night, and impaired optical quality causing monocular diplopia and ghosting.

While a single arbitrary objective measure might be desirable a specific Snellen visual acuity alone can neither rule in nor rule out the need for surgery. Visual acuity should be considered in the context of the patient’s visual impairment and other ocular findings.

Specialized Ophthalmic Testing

For circumstances where the placement of an intraocular lens (IOL) is anticipated, A-scan ultrasound testing or partial coherence interferometry, keratometry (may be from corneal topography), and IOL calculations and selection would be anticipated to be performed.

Additional ancillary testing as appropriate in the establishment or exclusion of medical necessity. This should be directed by specific patient complaint or symptom where possible.

Certain testing would not be anticipated to be required in a pre-operative workup when performing routine cataract surgery. These include, but are not limited to:

  1. B-Scan/Ultrasound of the Posterior Segment
  2. Glare Testing
  3. Brightness Acuity Testing
  4. Low-contrast visual acuity testing
  5. Contrast sensitivity testing
  6. Potential vision testing
  7. Formal visual fields
  8. Fluorescein angiography
  9. External photography
  10. Corneal pachymetry/specular microscopy
  11. Specialized color vision tests
  12. Electrophysiological tests

However, there may be legitimate reasons to perform these tests. For example (other reasonable examples are possible):

a.       B-scan ultrasound testing would be medically necessary to assess such structures for the purpose of surgical decision-making in circumstances where an adequate view of the intraocular structures cannot be obtained because of dense cataract,

b.       Glare testing/brightness acuity testing would be medically necessary in a patient with a complaint of difficulty driving at night, and

c.       Corrected Snellen visual acuity testing under low-contrast conditions or formal contrast sensitivity testing would be medically necessary to uncover or demonstrate functional impairments correlated with the patient's symptoms.

In general, any performed ancillary testing must be conducted so as not to deliberately bias the decision toward the performance of surgery (e.g., glare testing done on abnormally high settings inconsistent with the instructions of the testing device’s manufacturer, etc.), and must have results and indications of medical necessity properly documented. Ancillary tests that are not routinely indicated in the preoperative workup for cataract surgery will not be considered a covered benefit unless medical necessity for the particular patient's circumstances is clearly documented in the patient's record. (see Documentation Requirements in Local Coverage Article).

Second Eye Surgery

Should a significant cataract also be present in the second eye, as supported by Cataract in the Adult Eye, a “Preferred Practice Pattern” by the American Academy of Ophthalmology, except in special circumstances, surgery is generally not performed in both eyes at the same time because of the potential for bilateral visual loss.

In the more common situation where surgery is performed sequentially in the other eye on separate days for bilateral visually symptomatic cataracts the appropriate interval between the first-eye surgery and second-eye surgery is influenced by several factors:

  1. The patient's visual needs
  2. The patient's preferences
  3. Visual function in the second eye
  4. The medical and refractive stability of the first eye
  5. The need to restore binocular vision and resolve anisometropia,
  6. Allow an adequate interval of time to elapsed to evaluate and treat early postoperative complications in first eye, such as endophthalmitis; and/or
  7. Logistical and travel considerations of the patient.

The patient and the ophthalmologist should discuss the benefits, risks, need, and timing of second-eye surgery when they have had the opportunity to evaluate the results of surgery on the first eye, taking into account the above factors.

If the decision to perform cataract extraction in both eyes is made prior to the first (sequential) cataract extraction, the documentation must support the medical necessity for each procedure to be performed.

Complex Cataract Surgery 

Note that a procedure coded as “Complex Cataract Surgery” must meet all other requirements for Cataract Surgery as outlined above and in the associated Billing and Coding Article A57196.


Summary of Evidence


Analysis of Evidence (Rationale for Determination)


Proposed Process Information

Synopsis of Changes
Changes Fields Changed
Associated Information
Sources of Information
Open Meetings
Meeting Date Meeting States Meeting Information
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
MAC Meeting Information URLs
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
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Revenue Codes

Code Description


Group 1

Group 1 Paragraph


Group 1 Codes



ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:


Group 1 Codes:



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

Group 1

Group 1 Paragraph:


Group 1 Codes:



Additional ICD-10 Information

General Information

Associated Information
Sources of Information
  1. American Academy of Ophthalmology. Cataract and Anterior Segment Panel. Cataract in the Adult Eye Preferred Practice Pattern®. San Francisco, CA. 2016. 
  2. Gayer S, Zuleta J. Perioperative Management of the Elderly Undergoing Eye Surgery. Clinics in Geriatric Medicine. 2008;24(4):687-700.
  3. Yanoff M, Duker JS. Yanoff & Duker:Ophthalmology. 3rd ed. Mosby, An Imprint of Elsevier. 2008.
  4. American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, et al. Utilization, Appropriate Care, and Quality of Life for Patients with Cataracts. Ophthalmology. 2006;113(10):1878-82.




Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/30/2023 R3

The proposed LCD was taken to an Open Meeting on 03/09/2023 due to editorial changes throughout the policy. 

  • Provider Education/Guidance
10/01/2019 R2

Updated #1 under Sources of Information to remove broken link. 

  • Typographical Error
10/01/2019 R1

10/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage.

LCD was converted to the "no-codes" format.

  • Revisions Due To Code Removal

Associated Documents

Related National Coverage Documents
Public Versions
Updated On Effective Dates Status
06/09/2023 07/30/2023 - N/A Currently in Effect You are here
09/23/2022 10/01/2019 - 07/29/2023 Superseded View
09/20/2019 10/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.


  • Cataract
  • Surgery
  • Adult

Read the LCD Disclaimer