L29207-LCD

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Local Coverage Determination (LCD) for Iridotomy by Laser Surgery (L29207)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29207

LCD Title

Iridotomy by Laser Surgery

Contractor's Determination Number 66761

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the 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: N/A

Indications and Limitations of Coverage and/or Medical Necessity

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.

Medicare will consider iridotomy by laser surgery medically necessary and reasonable to treat acute, sub-acute, intermittent or 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.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

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

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations 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.

Appendices

Utilization Guidelines N/A

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.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2011

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revisionl Effective Date:10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added new diagnosis code 365.06. The effective date of this revision is based on date of service.

Revision Number1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2011 Revisionl Effective Date: 01/01/2011

LCR B2011-009

December 2010 Update

Explanation of Revision: Annual 2011 HCPCS Update. Descriptor revised for CPT code 66761. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29207) replaces LCD L13839 as the policy in notice. This document (L29207) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

66761 descriptor was changed in Group 1

Reason for Change