SUPERSEDED Local Coverage Determination (LCD)

Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy

L33946

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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33946
Original ICD-9 LCD ID
Not Applicable
LCD Title
Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
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 10/27/2022
Revision Ending Date
11/01/2023
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.

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Issue

Issue Description

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

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 -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.

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2:

    140.5‎ Laser Procedures

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Posterior capsule opacification (PCO) is one of the most common problems following cataract surgery. Anterior capsule opacification (ACO) also occurs, but somewhat less commonly. Both conditions represent the anatomic correlate of a secondary cataract (SC). As capsule opacification increases, the patient begins to notice a decrease in vision that can lead to functional impairment. The approach to the management of functional impairment due to SC, whether the result of ACO or PCO, or both, is similar to that of functional impairment due to cataract. Treatment of SC is reserved for those patients who have documented functional impairment that impacts their ability to perform needed and desired activities of daily living.

The time of onset of PCO is variable, as is the frequency with which surgery to treat PCO is performed. PCO severe enough to impair function significantly and thus require surgery is uncommon within three months of cataract surgery and occurs occasionally within the first six months after the surgery. Neodymium-Yttrium-Aluminum-Garnet YAG (Nd:YAG) posterior capsulotomy after cataract extraction has been reported as high as 30% to 50% in the early 1980s to 1990s. Although the rate for some lenses and techniques remains in the 25% - 30% range, the rate for other lenses and techniques has fallen to the single digits in some series.

PCO is a consequence of modern cataract surgery, whether performed by the extracapsular technique or by phacoemulsification (PE). In the past, an invasive procedure involving incision of the capsule with a knife, e.g., discission, was necessary to remove the opacity. Now, with the availability of the Nd:YAG laser, it is possible to perform laser capsulotomy after cataract surgery as an outpatient procedure. YAG capsulotomy for PCO creates an incision in the posterior capsule that normally serves as the boundary between the lens and the vitreous humor of the eye. The laser-created incision allows the capsule to retract, eliminating the obstruction to the passage of light through the media to the retina. YAG capsulotomy is currently the predominant means of treating a secondary cataract, in contrast to discission surgery, which is now only very rarely performed in adults as a primary procedure. However, for PCO due to an extremely dense membrane, or in those patients unable to tolerate or cooperate with laser surgery, invasive discission of the opacity is still an option.

With the development of modern cataract surgery techniques, specifically the continuous curvilinear capsulorrhexis, SC can also develop from opacification of the anterior capsule with, or without, shrinkage of the surgically created anterior capsular opening. Either situation is amenable to a YAG laser anterior capsulotomy for restoration of vision as well as for the prevention of intraocular lens decentration and/or frank dislocation.

The major complications of YAG capsulotomy include elevated intraocular pressure, retinal detachment, cystoid macular edema, damage to the intraocular lens, hyphema, decentration or dislocation of the intraocular lens, corneal edema, vitreous prolapse, endothelial cell loss, uveitis, and pupillary block, among others.

This policy will only address anterior and posterior capsulotomy for secondary cataract after cataract surgery.

Indications:

Post-cataract surgery Nd:YAG laser capsulotomy is reasonable and medically necessary only to remedy a functional impairment due to opacification, to prevent possible intraocular damage from dislocation of the intraocular lens implant, or the need to evaluate and treat posterior segment pathology. The procedure will not be covered if it is performed or scheduled concurrently with cataract-removal surgery.

Capsulotomy is covered when each of the following criteria are met and clearly documented:

  • The patient has decreased ability to carry out activities of daily living including (but not limited to) reading, watching television, driving, or meeting occupational or a vocational expectations; and
  • The patient has a best-corrected visual acuity of 20/50 or worse at distance or near; or additional testing shows one of the following:
    • Consensual light testing decreases visual acuity by two lines, or
    • Glare testing decreases visual acuity by two lines; and
  • The patient has determined that he/she is no longer able to function adequately with the current level of visual function; and
  • Other eye disease(s), including but not limited to macular degeneration or diabetic retinopathy, has (have) been excluded as the primary cause of visual functional disability, except for the instance in which significant visual debility, in the judgement of the treating physician, is deemed secondary to ACO or PCO and laser treatment would provide the patient with improved functionality; and
  • Physician concurrence with significant patient-defined improvement in visual function can be expected as a result of capsulotomy; and
  • The patient has been educated about the risks and benefits of capsulotomy and the alternative(s) to surgery (e.g., the avoidance of glare, use of optimal eyeglasses prescription, etc.); and
  • The patient has undergone an appropriate preoperative ophthalmologic evaluation.

For patients with a best-corrected visual acuity of 20/40 or better, anterior and/or posterior capsulotomy will be considered if all other criteria have been met and documented to support the medical necessity of the procedure for that patient.

Limitations:

YAG capsulotomy secondary to cataract extraction and intra-ocular lens placement should not be required more than once per eye. Claims for a second capsulotomy will require the patient have a non-cataract extraction related underlying diagnosis or condition that poses a high risk for re-opacification of the capsule.

Medicare recognizes the use of lasers for many medical indications. Procedures performed with lasers are sometimes used in place of more conventional techniques. In the absence of a specific noncoverage instruction, and where a laser has been approved for marketing by the Food and Drug Administration, contractor discretion may be used to determine whether a procedure performed with a laser is reasonable and necessary and, therefore, covered. The determination of coverage for a procedure performed using a laser is made on the basis that the use of lasers to alter, revise, or destroy tissue is a surgical procedure. Therefore, coverage of laser procedures is restricted to practitioners with training in the surgical management of the disease or condition being treated (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2: 140.5‎ Laser Procedures).

 

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
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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. CGS is not responsible for the continuing viability of Web site addresses listed below.

Aslam TM, Devlin H, Dhillon B. Use of Nd:YAG laser capsulotomy. Surv Ophthalmol. 2003;48:594-612.

Apple DJ, Peng Q, Visessook N, et al. Eradication of posterior capsule opacification. Documentation of a marked decrease in Nd:YAG laser posterior capsulotomy rates noted in an analysis of 5416 pseudophakic human eyes obtained postmortem. Ophthalmology. 2001;108:505-518.

Auffarth GU, Brezin A, Caporossi A, et al. Comparison of Nd:YAG capsulotomy rates following phacoemulsification with implantation of PMMA, silicone, or acrylic intra-ocular lenses in four European countries. Ophthalmic Epidemiology. 2004;11(4):319-329.

Bertelmann E, Kojetinsky C. Posterior capsule opacification and anterior capsule opacification. Curr Opin Ophthal. 2001;12(1):35-40.

Carrier Advisory Committee

Ge J, Wand M, Chiagn R, Paranhos A, Shields MB. Long-term effect of Nd:YAG laser posterior capsulotomy on intraocular pressure. Arch Ophthalmol. 2000;118(10):1334-1337.

Other Medicare contractors’ local coverage determinations

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/27/2022 R11

R11

Revision Effective: 10/27/2022

Revision Explanation: Annual Review, no changes

10/21/2022: 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.

  • Other (Annual Review)
10/21/2021 R10

R10

Revision Effective: 10/21/2021

Revision Explanation: Annual Review, no changes

10/15/2021: 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.

  • Other (Annual Review)
11/07/2019 R9

R9

Revision Effective: N/A

Revision Explanation: Annual Review, no changes

10/19/2020: 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.

  • Other (Annual Review)
11/07/2019 R8

Annual Review

  • Other (R8

    Revision Effective: 11/07/2019

    Revision Explanation: Annual Review, Removed other comments from Coverage Indications, Limitations and/or Medical Necessity and Associated Information based on TDL 190550. Added to A56493 - Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy,

    10/30/2019: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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
    )
09/19/2019 R7

R7

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019: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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
09/19/2019 R6

R6

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019: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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
04/18/2019 R5

R5

Revision Effective: 04/18/2019

Revision Explanation: Removed codes from policy based on CR 10901 and attached new billing and coding article.

04/08/2019: 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 determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Code Migration)
10/01/2015 R4

R4

Revision Effective: N/A

Revision Explanation: Annual review no changes made

10/30/2018: 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.

  • Other (Annual Review)
10/01/2015 R3

R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made

DATE (10/30/2017): 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.

  • Other (Annual Review)
10/01/2015 R2 R5
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual Review)
10/01/2015 R1 R1
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual Review)
N/A

Associated Documents

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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
10/27/2023 11/02/2023 - N/A Currently in Effect View
10/21/2022 10/27/2022 - 11/01/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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