LCD/NCD Portal

L29207

 

IRIDOTOMY BY LASER SURGERY

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• Medicare will consider iridotomy by laser surgery medically necessary and reasonable to treat

o acute,

o sub-acute,

o intermittent or

o Chronic angle-closure glaucoma.

• Laser iridotomy can successfully eliminate the chance of acute or chronic angle-closure glaucoma in most cases.

• Additionally, when a patient is noted to have an occludable angle upon gonioscopic examination, even in the absence of symptoms, a peripheral iridotomy may be performed to prevent angle-closure glaucoma.

• When laser iridotomy is not possible (e.g., because patients are uncooperative or severe corneal edema persists), incisional iridectomy remains an effective alternative.

• Following iridotomy or iridectomy, further treatment may be required for elevated intraocular pressure (IOP) in the residual stage of angle-closure when drainage function has been compromised by the formation of adhesions between the iris and trabecular meshwork or by other damage to the trabecular meshwork.

• This procedure is NOT indicated for open angle glaucoma.

 

CPT/HCPCS Codes

 

 

66761 IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)

 

 

ICD-9 Codes that Support Medical Necessity

 

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.06 PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

365.13 PIGMENTARY OPEN-ANGLE GLAUCOMA

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA

365.22 ACUTE ANGLE-CLOSURE GLAUCOMA

365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA

365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA

365.83 AQUEOUS MISDIRECTION

 

 

Documentation Requirements

• The patient’s medical record must clearly show the medical necessity of performing the procedure including, but not limited to, the symptoms experienced by the patient, the intraocular pressure and the status of the angle as evaluated with gonioscopy.

Treatment Logic

• Iridotomy by laser surgery is a procedure to treat a variety of angle-closure glaucomas that have at least some component of pupillary block.

• This procedure allows the aqueous to bypass the pupillary block and eliminates the pressure gradient between the posterior and anterior chambers.

• The iridotomy reverses the appositional angle closure, and it prevents or retards formation of peripheral anterior synechiae.

Sources of Information and Basis for Decision

 

Acute Angle –Closure Glaucoma, Treatment. Retrieved from e-medicine at www.emedicinehealth.com/articles/37853-6 on August 9, 2005.

 

American Academy of Ophthalmology (2000). Preferred Practice Pattern; Primary angle-closure. National Guideline Clearinghouse. Retrieved January 15, 2003 from http://www.guideline.gov/index FRAME sets/guidelines_fs.asp?guideline=001774. This document was used to support the indications and limitations of coverage.

 

American Medical Association. (1998). A look at the Eye and Ocular Adnexa Codes. cptTM Assistant,8(12), 1-4. This source was used to clarify the phrase “one or more sessions”.

 

Friedman, D.S., (2001). Who needs an iridotomy? British Journal of Ophthalmology. Retrieved January 14, 2003, from www.http://bjo.bmjjournals.com. This source was used to explain and define indications for the procedure.

 

Hess, C. (2004). Laser Iridotomy for Glaucoma. Retrieved from www.my.webmd.com/hw/healthy_seniors/hw155031.asp on August 9, 2005.

 

10/01/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29207 Iridotomy by Laser Surgery