Medicare Advantage

Medical Policy

Title:

Cataract Surgery

Policy #:

MA11.054e

Policy

CATARACT SURGERY

MEDICALLY NECESSARY
Cataract surgery, with or without implantation of a conventional intraocular lens (IOL), is considered medically necessary and, therefore, covered when individual has an impairment of visual function due to cataract(s) resulting in the decreased ability to carry out activities of daily living (ADL) such as reading, viewing television, driving, or meeting occupational or vocational expectations with documentation of the following if they exist:

The individual has been educated about the risks and benefits of cataract surgery, the alternatives to surgery, and has provided informed consent.
The individual has undergone a formal measure that documents the individual's inability to function satisfactorily due to visual impairment while performing various ADLs.
The individual has monocular diplopia due to a cataract in the affected eye.
The individual has worsening angle closure due to increase in size of the crystalline lens.

Cataract surgery may be considered medically necessary in individuals undergoing concurrent surgery in the same eye, such as a trabeculectomy or a corneal transplant, and in whom a significant cataract is found. In these individuals, the treating surgeon may deem the decreased morbidity of single-stage surgery to be of significant benefit over surgery on separate dates.

In rare instances (e.g., cases of extreme hyperopia or microphthalmos where an IOL would not provide adequate refractive power to achieve emmetropia), insertion of two IOLs (Piggyback) at the time of the initial cataract surgery may be considered medically necessary.

The criteria below are intended to define medically necessary scenarios in which a cataract surgery procedure may require extraordinary work and necessitate the billing of a complex cataract service:

A miotic pupil that will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and that requires one or more of the following techniques:
- The insertion of multiple iris retractors through multiple additional incisions
- Pupil expansion device or technique (e.g., manual pupil stretching, Beehler expansion device, Malyugin ring)
- A sector iridectomy with subsequent suture repair of iris sphincter or sphincterotomies created with scissors
Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the IOL.
Pediatric cataract surgery, which may be more difficult intraoperatively because of an anterior capsule that is more difficult to tear, a cortex that is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorrhexis.
Mature cataract requiring dye for visualization of capsulorrhexis.
Extraordinary work that 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.

NOT MEDICALLY NECESSARY
Cataract surgery performed in individuals who do not meet the criteria described in this policy is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, cataract surgery is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous products approved by the FDA for intraocular lens (IOL) implantation during cataract surgery.

Description

A cataract is an opacity, or lack of optical uniformity of the crystalline lens of the eye, and is a common cause of impaired visual function. The cloudiness and resulting loss of transparency are caused by the clumping of the protein content of the lens. Cataracts develop on a continuum, ranging from minute changes in the transparency of the lens to complete opacity. Early stages of cataract formation may be gradual and not accompanied by any noticeable, detrimental effect on an individual's visual function. However, the later stages of cataract development may decrease visual acuity to only light, dark, and shadows.

There are several risk factors associated with the development of cataracts: the most common are age related (e.g., advancing chronological age), prolonged exposure of the eyes to sunlight (ultraviolet B light exposure), systemic diseases (e.g., diabetes), smoking, and protracted use of certain medications (e.g., steroids).

Although cataract formation is usually experienced as part of the aging process, a cataract may form at any age. Adults may experience normal, age-related changes in visual acuity that include the development of cataracts. Decreased functional capacity and quality of living are adversely associated with cataract formation, and may lead to a lessening of an individual's capability to carry out activities of daily living. This reduction in ADLs may include, but is not limited to, a diminished ability for reading, driving, meeting occupational or vocational expectations, and an increased risk of accidental injury (e.g., falls).

Cataract formation usually causes the following visual symptoms: blurred and/or double vision, colors fading, sensitivity to light (or a halo/glare effect), decreased vision, the appearance of a milky pupil with flashlight examination, and the tendency for nearsightedness or for multiple changes to prescription eyeglasses.

According to the American College of Eye Surgeons, visual function includes the following factors:

Resolution of high-contrast objects: traditionally known as Snellen visual acuity; central, intermediate, and distance vision measured with a near card or an eye chart.
Contrast sensitivity: the ability to distinguish objects from similarly colored backgrounds in various levels of light. A measurement of the contrast level necessary for detection of a specified size of an object; highly indicative of the speed of recognition of fast-moving visual targets.
Field of vision: the total area visible to an eye without movement, including objects that can be seen in the side (peripheral) vision while the eyes are focused on a central point.
Stereopsis/binocular vision: the separate images from both eyes effectively combined into one image in the brain.
Spatial orientation/depth perception: the ability to judge the size, distance, and spatial relationship between objects in the visual field.
Color perception: the mental processing of chromatic stimuli from the eye as symbolically represented in the visual cortex of the brain.

In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate intraocular lens (IOL) are sufficient prior to surgery. For individuals with a simple cataract, a diagnostic ultrasound A scan is generally used. For individuals with a dense cataract, an ultrasound B scan may be used. In general, only one type of scan and one comprehensive eye examination are necessary prior to cataract surgery.

The accepted time interval between the preoperative examination and the date of the cataract surgery is usually 3 months or less.

SURGICAL PROCEDURES

A cataract may be successfully treated with surgical removal. Cataract surgery is usually indicated for best-corrected (e.g., after refraction) Snellen visual acuity of 20/40 or worse, attributed to a diagnosis of cataract from the appropriate, comprehensive, preoperative ophthalmologic evaluation. In addition, the inability to carry out occupational (e.g., pilot) activities and/or ADLs without visual interference may be a cause for cataract surgery. The individual should be educated on the outcomes and potential risks of cataract surgery.

COMPLICATIONS
Complications following cataract surgery are generally uncommon. The most common long-term complication of cataract surgery is known as "after cataract," a capsular opacification of the surgically implanted lens.

Possible complications following cataract surgery include, but are not limited to:

Displacement of the new implanted lens
Edema of the cornea, which may be transient or permanent (pseudophakic bullous keratopathy)
Endophthalmitis, an infection of the intraocular tissues
Glaucoma, an increase in the intraocular pressure (IOP) of the eye
Posterior capsular tear, a rupture in the posterior capsule of the lens
Retinal detachment
Toxic anterior segment syndrome (TASS)
Uveitis
Vitreous prolapse, which may result in vitrectomy for the affected eye
Cystoid macular edema

The goal of cataract surgery is to restore an individual's visual acuity and functioning level. The use of 20/40 as the threshold for postoperative visual acuity is based on the peer-reviewed literature standard that this value is indicative of a successful surgical outcome. Additionally, the US Food and Drug Administration (FDA) uses this value as an assessment parameter in the approval of IOLs and other devices for vision. Lastly, 20/40 is the visual acuity level required in most US states for unrestricted motor vehicle operation.

Cataract surgery is performed to remove the opaque natural crystalline lens of the eye. A new, artificial, and conventional IOL implant is usually inserted into the eye to restore transparency and vision. Achieving visual acuity of 20/40 or better after cataract surgery reflects the appropriateness and accuracy of the axial length and corneal power measurements. If a corrective IOL is used, the power calculation formula is used to select the appropriate IOL for implantation. This implantation is accomplished either through a small incision (1.8 mm to 2.8 mm) or through an enlarged incision, usually using a polymethylmethacrylate (PMMA) lens.

Rarely, in individuals requiring vitrectomy, cataract surgery without IOL implantation may be done to improve the likelihood of retinal re-attachment. Currently, there are two principal types of cataract surgeries performed: phacoemulsification (phaco) and conventional extracapsular cataract extraction (ECCE). Both of these surgeries usually involve the insertion of an IOL. Phaco and ECCE have superseded intracapsular cataract extraction (ICCE).

Phaco is the most commonly performed cataract surgery. This technique involves a small (2–3 mm) incision that may be made in different locations, including the clear cornea, limbus, or sclera of the eye. A probe is inserted through the incision to supply ultrasonic waves to break up and emulsify the crystalline lens, and then the lens remnants are removed with suction. The small incision rarely requires sutures and lends itself to unnoticeable wound closure when necessary.

ECCE uses an incision (10–12 mm) that usually requires stitching, although sutureless ECCE is also in use. Conventional ECCE involves manual expression of the lens through an incision made in the cornea or sclera. Although it requires a larger incision and the use of stitches, the conventional method may be indicated for individuals with very hard cataracts or other situations in which phaco surgery is problematic.

Microincision cataract surgery involves a technique by which a cataract can be reached through an incision of 1.5 mm or less.

COMPLEX CATARACT SURGERY

The extent of work performed during the intraoperative and/or postoperative stages of cataract surgery determines the overall complexity of the surgery. Examples of indications that require complex cataract surgery include, but are not limited to the following:

A miotic pupil requiring the insertion of multiple iris retractors through multiple additional incisions, pupil expansion device or technique (e.g., manual pupil stretching), a sector iridectomy with or without subsequent suture repair of iris sphincter, or sphincterotomies created with scissors.
Abnormally weak or absent lens support structures due to the presence of a comorbidity (e.g., pseudoexfoliation) that necessitates the use of a capsular support ring or sutured IOL
Pediatric cataract surgery.
Dense cataracts that require the use of capsular dye to assist in the visualization of the anterior capsule when performing capsulorrhexis.

References

American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern®. San Francisco, CA: American Academy of Ophthalmology; 2016. Also available on the AAO Web site at: http://www.aaojournal.org/article/S0161-6420(16)31418-X/pdf. Accessed April 1, 2024.

American Academy of Pediatrics (AAP). Eye examination in infants, children, and young adults by pediatricians. Pediatrics. 2003;111(4 Pt 1):902-7. Reaffirmed May 2007.

American College of Eye Surgeons (ACES). Guidelines for cataract practice. 2001 [Archived September 12, 2014]. Available at: http://cdn.ca9.uscourts.gov/datastore/library/2014/09/12/Colwell_Guidelines.pdf. Accessed April 1, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (10.1). [CMS Web site]. Original: 08/31/1992. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=60&ncdver=1&CoverageSelection=National&ncd_id=10.1&ncd_version=1&basket=ncd:10.1:1:Use+of+Visual+Tests+Prior+to+and+General+Anesthesia+during+Cataract+Surgery&bc=gAAAABAAAAAA&. Accessed April 1, 2024.

Chang DF, Henderson BA, Lee RH, et al. American Academy of Ophthalmology Preferred Practice Pattern: Cataract in the Adult Eye. Cataract and Anterior Segment Preferred Practice Pattern Panel 2010-2011.

Chou R, Dana T, Bougatsos C. Screening older adults for impaired visual acuity: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(1):44-58, W11-20.

Craven ER, Katz LJ, Wells JM, et al. Cataract Surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: Two-year follow-up. J Cataract Refract Surg. 2012;38:1339-1345.

Jacobs D.S. Cataracts in Adults. 02/29/2024. Up to Date. [UpToDate Web site]. Available at: http://www.uptodate.com/home/index.html. [via subscription only]. Accessed April 1, 2024.

Moseley M, Hill A. Contrast sensitivity testing in clinical practice. Br J Ophthalmol. 1994;78: 795-797.

National Eye Institute. Facts about cataract. [NEI Web site]. August 2019. Available at: https://nei.nih.gov/health/cataract/cataract_facts. Accessed April 1, 2024.

National Institute for Health and Clinical Excellence (NICE). Interventional Procedures Programme. Interventional procedure overview of the implantation of accommodating intraocular lenses during cataract surgery. August 2006. [NICE Web Site]. Available at: https://www.nice.org.uk/guidance/ipg209/documents/implantation-of-accommodating-intraocular-lenses-during-cataract-surgery-interventional-procedures-overview2. Accessed April 1, 2024.

Novitas Solutions, Inc. Local Coverage Article: Cataract Extraction (including Complex Cataract Surgery) (A56615). [Novitas Solutions, Inc. Web site]. Revised: 07/11/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56615&ver=31&bc=0. Accessed April 1, 2024.

Novitas Solutions, Inc. Local Coverage Determination (LCD): Cataract Extraction (including Complex Cataract Surgery) (L35091). [Novitas Solutions, Inc. Web site]. Revised: 07/11/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35091&ver=103. Accessed April 1, 2024.

Obstbaum SA, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, European Society of Cataract and Refractive Surgeons. White paper: Utilization, appropriate care, and quality of life for patients with cataracts. J Cataract Refract Surg. 2006;32(10):1748-52.

Owsley C, McGwin G Jr, Scilley K, et al. Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol. 2007;91(10):1359-63.

Royal College of Ophthalmologists (RCO). Cataract Surgery Guidelines. London, United Kingdom. 2010. [RCO Web site]. Available at: https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-SCI-069-Cataract-Surgery-Guidelines-2010-SEPTEMBER-2010-1.pdf. Accessed April 1, 2024.

U.S. Preventive Services Task Force. Chapter 33 Screening for visual impairment. In: Guide to Clinical Preventive Services.2nd ed. Rockville, MD Agency for Healthcare Research and Quality; 1996.

Vasavada A, Singh R. Phacoemulsfication in eyes with a small pupil. J Cataract Corrective Surg. 2000;26:1210-1218.

Coding

CPT Procedure Code Number(s)

66840, 66850, 66852, 66920, 66940, 66982, 66983, 66984, 66987, 66988

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.054e:

06/17/2024

This version of the policy will become effective 06/17/2024.

The following Current Procedural Terminology (CPT) codes have been deleted from this policy: 66989, 66991, and 0699T.

Codes 66989 and 66991 can be found in cross-referenced policy MA11.105 Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma.

Revisions From MA11.054d:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
11/16/2022	This policy has been reissued in accordance with the Company's annual review process.
01/01/2022	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the CPT code update, effective 01/01/2022. The following CPT codes have been added to this policy: 66989 (Medically Necessary), 66991 (Medically Necessary), 0699T (Medically Necessary)

Revisions From MA11.054c:

06/02/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on Cataract Surgery.
06/03/2020	This policy has been reissued in accordance with the Company's annual review process.
01/01/2020	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the CPT code update, effective 01/01/2020. The following CPT codes have been added to this policy: 66987 (Medically Necessary), 66988 (Medically Necessary) The narrative was revised for the following CPT codes: 66982, 66984

Revisions From MA11.054b:

05/22/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Cataract Surgery.
03/28/2018	This policy has undergone a routine review, and no revisions have been made.
09/27/2017	This version of the policy will become effective 09/27/2017. Medical necessity criteria were updated. The following CPT codes have been removed from this policy: 66830, 66930. The following ICD-10 CM codes have been added to Attachment A in this policy: H21.569, H26.231, H26.232, H26.233, H26.239, H40.89, H53.2.

Revisions From MA11.054a:

06/01/2016

This version of the policy will become effective 06/01/2016.

The following criteria prior to cataract surgery have been added to the policy section:

The individual has worsening angle closure due to increase in size of the crystalline lens.

Additionally, the criterion addressing visual field loss has been revised to make it more specific:

FROM: Visual field loss
TO: The individual has worsening central vision field loss.

Revisions From MA11.054:

01/21/2015	This policy has been reviewed and reissued to communicate the Company’s continuing position on Cataract Surgery.
01/01/2015	This is a new policy.

Version Effective Date:

6/17/2024

Version Issued Date: