Cataract Extraction

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.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Part 1:

10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery 260 Ambulatory Surgical Center Services

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

10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery 80.8 Endothelial Cell Photography 80.10 Phaco-Emulsification Procedure - Cataract Extraction

Abstract:

A cataract is an opacity or cloudiness in the lens of the eye(s), blocking the passage of light through the lens, sometimes resulting in impaired vision. Cataract development occurs in 60% of adults 65 years of age or greater. There are multiple factors associated with cataract development. Some causes of cataracts may include: ultraviolet-β radiation exposure, complications of diabetes, drug and/or alcohol use, smoking, and the natural process of aging. Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This policy defines coverage and describes criteria necessary to justify the performance of cataract extraction(s) or other select lensectomies.

Indications and Limitations:

Indications:

Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries who have a cataract, and who meet all of the following criteria:

The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:

• Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
• The patient has a best corrected visual acuity of 20/50 or worse at distant 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
• The patient has determined that he/she is no longer able to function adequately with the current visual function; and
• Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and
• Significant improvement in visual function can be expected as a result of cataract extraction; and
• The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
• The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.

Cataract extraction may be covered when an unimpeded view of the fundus is mandatory for proper management of patients with diseases of the posterior segment of the eye(s).

Cataract extraction may be covered during vitrectomy procedures if it is determined that the lens interferes with the performance of the surgery for far peripheral vitreoretinal dissection and excision of the vitreous base, as in cases of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy.

For patients with a best corrected visual acuity of 20/40 or better, cataract extraction will be considered if all other criteria have been met and there is substantial documentation of the medical necessity of the procedure for that patient.

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

Bilateral cataract extraction performed on both eyes, on the same date of service is termed immediate sequential bilateral cataract surgery (ISBCS). ISBCS as an approach to bilateral cataract extraction may afford certain clinical benefits but carries with it, the possibility of bilateral visual loss. The decision to perform ISBCS should be an individual decision, made jointly by the patient and physician. The medical record must document the rationale for ISBCS and that the patient has been apprised of the risks and benefits of both this approach and of the available alternatives.

If the first cataract extraction is performed and a subsequent contralateral cataract extraction is considered, the criteria for coverage of the procedure in the contralateral eye are the same as the criteria for the first cataract extraction.

Complex Cataract Surgery (CPT code 66982)

The code for complex cataract surgery (CPT code 66982) is intended to differentiate the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations including, and not limited to, the following:

• A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and which requires the insertion of four (4) iris retractors through four (4) additional incisions, Beechler or similar expansion device, a sector iridectomy with subsequent suture repair of iris sphincter,synechialysis tuilizing papillary stretch maneuvers or sphincterotomies created with scissors.
• The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures and/or a capsular support ring (approved by the FDA) may be necessary to allow placement of an intraocular lens.
• Pediatric cataract surgery may be more difficult intraoperatively because of an anterior capsule which is more difficult to tear, cortex which is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorhexis. Furthermore, there is additional postoperative work associated with pediatric cataract surgery.
• Extraordinary work may occur during the postoperative period. This is the case with pediatric cases mentioned above and very rarely when there is extreme postoperative inflammation and pain.

The “Documentation Requirements” section of the policy provides a list of diagnosis codes to be reported with CPT code 66982 in specified circumstances.

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for cataract extraction services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

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The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The medical record and/or test results documenting medical necessity should be maintained and made available on request.

If cataract extraction is performed due to anisometropia, the medical record must substantiate the presence of significant aniseikonia secondary to anisometropia arising from the first cataract extraction with IOL implant. The medical record must reflect that the aniseikonia is visually significant to the patient by documenting the patient's subjective complaints and must also document that anisometropia is present by determination of the refractive error in both eyes after the first cataract surgery.

If cataract extraction is performed in order to visualize the fundus, the disease being treated must appear in the medical record, and the necessity for visualization must be described in the medical record.

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.

American Academy of Ophthalmology. Cataract in the Adult Eye, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2006. Available at: www.aao.org/ppp. Accessed 04/04/2008.

Carrier Advisory Committee

Other Medicare local coverage determinations especially Wheatlands Administrative Services, Inc. (L22215 – Complex Cataract Surgery)

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