Local Coverage Determination (LCD)

YAG Capsulotomy

L37644

Expand All | Collapse All

Contractor Information

LCD Information

Document Information

LCD ID
L37644
LCD Title
YAG Capsulotomy
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 01/29/2018
Revision Effective Date
For services performed on or after 03/10/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/14/2017
Notice Period End Date
01/28/2018
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, 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

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

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, §1862(a)(7) excludes routine physical examinations.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Neodymium-doped Yttrium Aluminum Garnet (YAG) laser capsulotomies are performed in cases of opacification of the posterior capsule, generally no less than 90 days following cataract extraction. YAG performed less than 90 days following cataract extraction should meet both the indications and limitations of this Local Coverage Determination (LCD). The percentage of patients having this procedure varies greatly among ophthalmologists. Diagnosis of functional visual impairment due to capsular opacification is based on clinical judgment regarding 1 or more of the following:

  1. Visual loss and/or symptom of glare (visual acuity 20/30 or worse under Snellen conditions, using contrast sensitivity, or simulated glare testing);
  2. Symptoms of decreased contrast;
  3. Amount of posterior capsular opacification or;
  4. Other possible causes of decreased vision following cataract surgery.

Limitations

This procedure will not be covered within 3 months post cataract surgery unless justified by 1 of the following indications:

  1. Posterior capsular plaque/opacity which cannot be safely removed during primary phacoemulsification cataract procedure
  2. Capsular block during which cataract remnants and fluid become trapped within the lens capsule and addressed with YAG laser posterior capsulotomy
  3. Contraction of the posterior capsule with displacement of the intraocular lens.
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

  1. All coverage criteria must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

  2. The justification for a YAG capsulotomy procedure performed less than 3 months after cataract surgery, as described in the Limitations section of this LCD, should be clearly documented in the medical record.
Sources of Information

N/A

Bibliography

American Academy of Ophthalmology. Cataract in the Adult Eye, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2016. Accessed 2/1/22.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
03/10/2022 R6

Under Bibliography revised the broken hyperlink for the reference. Formatting and punctuation were corrected throughout the LCD.

  • Provider Education/Guidance
05/28/2020 R5

Under Bibliography changes were made to citations to reflect AMA citation guidelines and to update hyperlink. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/24/2019 R4

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: YAG Capsulotomy A56792 article.

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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
08/08/2019 R3

All coding located in the Coding Information section has been moved into the related Billing and Coding: YAG Capsulotomy A56792 and removed from the LCD. 

Punctuation and typographical errors were corrected throughout the LCD.

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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
02/26/2018 R2 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R1

The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.

  • Other

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56792 - Billing and Coding: YAG Capsulotomy
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
03/03/2022 03/10/2022 - N/A Currently in Effect You are here
05/21/2020 05/28/2020 - 03/09/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Yag
  • Capsulotomy
  • Cataract

Read the LCD Disclaimer