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Cataract Removal Surgery

Policy Number: MP-190

Latest Review Date: August 2021

Category:  Surgery                                                                 

POLICY:

Cataract Removal Surgery may be considered medically necessary when:

  1. The patient’s visual acuity is less than or equal to 20/50 (best corrected) as defined subjectively by Snellen visual acuity testing; AND
    • The patient has symptomatic impairment of visual function resulting in unsatisfactory ability to carry out ADLs (activities of daily living) (e.g. reading, viewing television, driving, meeting occupational/vocational expectations); and
    • The patient’s history includes the patient’s own assessment of his functional status; and
    • The patient has undergone an appropriate ophthalmologic evaluation; OR
  1. Cataract extraction is required to adequately diagnose or treat ocular conditions, such as, but not limited to, diabetic retinopathy.

Implantation of crystalens or other accommodative lenses is considered not medically necessary

Note:

When accommodative lenses are used with cataract extractions, a conventional intraocular lens (IOL) will be a covered service when all the above medical criteria for coverage are met.  Providers may bill the patient the additional expenses associated with insertion of accommodative lenses if the patient signs a waiver specific to non-coverage of accommodative lenses for the specific date of service, the lens is inserted. 

Examples of accommodative lenses, including, but not limited to: AcrySof® Toric, ReZoom®, Tecnis® Multifocal, AcrySof® ReSTOR® Apodized Diffractive Optic Posterior Chamber Intraocular Lenses to correct presbyopia

DESCRIPTION OF PROCEDURE OR SERVICE:

A cataract is an opacity of the lens that reduces the amount of incoming light and results in visual function deterioration. Cataract removal surgery should be considered as a treatment when the cataract causes severely limited ability to perform ADLs. ADLs that are typically regarded important by a patient are the ability to read, view television, drive, or meet occupational/vocational expectations. A patient’s tolerance of visual impairment is highly subjective and varies per personal perception. In addition to subjective indicators, there are also objective indicators that can be used when deciding that surgery should be the treatment path for cataracts. The Snellen chart (also known as Snellen visual acuity testing) is frequently used as a screening tool to objectively measure visual acuity. Visual acuity should be recorded and considered in the context of the patient’s visual impairment and other ocular findings.

While cataract surgery is generally accepted as a low risk surgery, it does carry risk of complication (such as capsular problems, dropped nucleus or lens fragments into vitreous, return to operating theatre, endophthalmitis, persistent corneal edema, and other). The decision to have this procedure performed should be carefully evaluated to determine that the risk outweighs the potential benefit. Cataracts only need to be removed when they cause significant vision loss and disruption to a patient’s ability to adequately function or in the case of the need to properly visualize, treat, and monitor retinal disease.

An appropriate preoperative evaluation should be performed prior to surgery. This generally includes a comprehensive ophthalmologic exam and A-scan ultrasound. Other ophthalmologic studies should be reserved for special situations. It is also appropriate to evaluate the patient for physical fitness of undergoing general anesthesia with respect to underlying co-morbidities such as heart disease, lung disease, etc.

KEY POINTS:

Literature review was last performed through July 27, 2021.

Summary of evidence

The evidence is sufficient to support the medical necessity of cataract removal surgery when significant, debilitating visual acuity compromise has been subjectively and objectively proven and the patient has been sufficiently educated on the disease process and treatment options.

Practice Guidelines and Position Statements

The American Academy of Ophthalmology (AAO) issued guidelines for the use of cataract surgery in the adult eye in 2016 as below:

Indications for Surgery:

The primary indication for surgery is visual function that no longer meets the patient’s needs and for which cataract surgery provides a reasonable likelihood of improved vision. Other indications for a cataract removal include the following:

  • There is clinically significant anisometropia in the presence of a cataract
  • The lens opacity interferes with optimal diagnosis or management of posterior segment conditions
  • The lens causes inflammation or secondary glaucoma (phacolytic, lens particle, phacoanaphylactic)
  • The lens induces or risks angle closure

KEY WORDS:

Cataracts, visual function, visual acuity, intraocular lens (IOL), phacoemulsification, crystalens™, accommodative IOL (AIOL), accommodative lens, AcrySof® ReSTOR® Apodized Diffractive Optic Posterior Chamber Intraocular Lenses, Tecnis® Multifocal Foldable Silicone and Acrylic Intraocular Lenses-P080010, Toric lens, ReZoom®, Tecnis® Multifocal

APPROVED BY GOVERNING BODIES:

Numerous intraocular lens implants have received FDA approval for implantation. FDA approval does not indicate medical necessity.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:                

66830

Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy)

66840

Removal of lens material; aspiration technique, one or more stages

66850

Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration

66852    

Removal of lens material; pars plana approach, with or without vitrectomy

66920 

Removal of lens material; intracapsular

66930

Removal of lens material; intracapsular, for dislocated lens

66940  

Removal of lens material; extracapsular (other than 66840, 66850, 66852)

66982

Extracapsular cataract removal with insertion of intraocular lens prosthesis (one-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation

66983 

Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure)

66984 

Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation

66985 

Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal

0514T

Intraoperative visual axis identification using patient fixation (List separately in addition to code for primary procedure)

HCPCS Codes:      

V2787

Astigmatism correcting function of intraocular lens

V2788  

Presbyopia correcting function of intraocular lens

 

REFERENCES:

  1. American Academy of Ophthalmology (AAO). Preferred Practice Patterns®: Cataract in the adult eye. Updated October 2016. For additional information: http://one.aao.org/ce/practiceguidelines/. Accessed on July 29, 2021
  2. Agency for Healthcare Research and Quality (AHRQ). Preoperative evaluation for elective cataract surgery - systematic review, AHRQ 2001, Rockville, MD.
  3. Aslam, T.M., Devlin, H., Dhillon, B. Use of Nd:  YAG laser capsulotomy, Surv Ophthalmol. 2003; 48(6): 594-612.
  4. Baratz, K.H., Cook, B.E., Hodge, D.O. Probability of Nd:  YAG laser capsulotomy after cataract surgery in Olmsted County, Minnesota. Am J Ophthalmol 2001; 131(2): 161-166.
  5. Cataract Management Guideline Panel. Cataracts in Adults:  Management of functional impairment. Clinical practice guideline, number 4, U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, AHCPR Pub. No. 93-0542. February 1993.
  6. Edelhart, C. Knowing when it’s time for cataract surgery. Eye Health. Michigan Health. 2016. https://healthblog.uofmhealth.org/health-management/knowing-when-its-time-for-cataract-surgery. Retrieved July 27, 2021
  7. Fogla R, Rao SK. Model eye for Nd:  YAG laser capsulotomy. J Cataract Refract Surg, 2000; 26(10): 1435-1437.
  8. ICHOM (International Consortium for Health Outcomes Measurement). Standard set for cataract surgery. https://www.ichom.org/portfolio/cataracts/. Retrieved July 26, 2021.
  9. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
  10. Kramar A, Grabner G, Seyeddain O, et al. Multifocal versusmonofocal IOLs:  No clear winner in small study, Cataract & Refractive Surgery Today Europe 2008;16-18.
  11. Olson, Braga-Mele, Huang Chen, et al. Cataract in the Adult Eye Preferred Practice Pattern. AAO Journal. 2017; 124 (2): 1-119.
  12. Queirós, L., Redondo, P., França, M., Silva, S. E., Borges, P., de Melo, A. B., Pereira, N., da Costa, P. F., Carvalho, N., Borges, M., Sequeira, I., Gonçalves, F., & Lemos, J. (2021). Implementing ICHOM standard set for cataract surgery at IPO-Porto (Portugal): clinical outcomes, quality of life and costs. BMC ophthalmology, 21(1), 119.

POLICY HISTORY:

Medical Policy Group, July 2004 (4)

Medical Policy Administration Committee, August 2004

Available for comment August 24-October 7, 2004

Medical Policy Group, April 2005 (2)

Medical Review Committee, May 2005

Medical Policy Administration Committee, May 2005

Available for comment May 9-June 22, 2005

Medical Policy Group, July 2005 (2)

Medical Policy Administration Committee, July 2005

Available for comment, July 30-September 12, 2005

Medical Policy Group, December 2005 (4)

Medical Policy Group, February 2009 (4)

Medical Policy Group, March 2011 (3); Updated effective date for Code Q1003

Medical Policy Group, September 2012 (3): Active Policy but no longer scheduled for regular literature reviews and updates.

Medical Policy Group, January 2018: (6): Updates to policy statement with no change in policy intent, Key Words and Coding section.

Medical Policy Group, December 2018: 2019 Annual Coding Update.  Added new CPT code 0514T.

Medical Policy Group, November 2019 (6): Updates to Description, Key Points, Governing Bodies, Practice Guidelines, Key Words (ReZoom®, Tecnis® multifocal), Coding (66830,66982,66985) and References. No change to policy intent.

Medical Policy Group, December 2019 (6) 2020 Annual coding update, Revised code 66984 to include “without endoscopic cyclophotocoagulation”.

Medical Policy Group, November 2020 (9): Updated Description for clarification purposes. Removed statement: "Experts state that cataract removal surgery should be performed on each eye separately and sufficient time be allowed for the first eye to heal before the second cataract removal is performed (an interval of 2 to 6 months is customary)." No change to policy statement or intent of coverage.

Medical Policy Group, August 2021 (9): Updated Description, Key Points, References. Policy statement verbiage updated for clarity and readability. No change to intent of coverage. Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy.


This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.