LCD/NCD Portal

L29211

 

LASER TRABECULOPLASTY

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will consider Argon Laser Trabeculoplasty (ALT), Selective Laser Trabeculoplasty (SLT), and Diode Laser Trabeculoplasty (DLT) medically necessary and reasonable for the following indications:

• Primary treatment for open-angle glaucoma

• Primary open-angle glaucoma when the raised intraocular pressure is unresponsive to topical or oral medications.

• Primary open-angle glaucoma with normal pressure and evidence of optic nerve damage.

 

CPT/HCPCS Codes

 

 

65855 TRABECULOPLASTY BY LASER SURGERY, 1 OR MORE SESSIONS (DEFINED TREATMENT SERIES)

 

 

ICD-9 Codes that Support Medical Necessity

 

 

365.01 OPEN ANGLE WITH BORDERLINE FINDINGS, LOW RISK

365.04 OCULAR HYPERTENSION

365.05 OPEN ANGLE WITH BORDERLINE FINDINGS, HIGH RISK

365.10 OPEN-ANGLE GLAUCOMA UNSPECIFIED

365.11 PRIMARY OPEN ANGLE GLAUCOMA

365.12 LOW TENSION OPEN-ANGLE GLAUCOMA

365.13 PIGMENTARY OPEN-ANGLE GLAUCOMA

365.14 GLAUCOMA OF CHILDHOOD

365.15 RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.32 CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.52 PSEUDOEXFOLIATION GLAUCOMA

 

 

Documentation Requirements

• Documentation such as the patient’s medical record should demonstrate the medical necessity for the

o Argon Laser Trabeculoplasty (ALT),

o Selective Laser Trabeculoplasty (SLT), or

o Diode Laser Trabeculoplasty (DLT) procedure.

• The medical record should include documentation of symptoms, intracocular pressure, the status of the angle and the status of the disc.

 

Treatment Logic

• Argon Laser Trabeculoplasty (ALT), Selective Laser Trabeculoplasty (SLT), and Diode Laser Trabeculoplasty (DLT) are options used in the treatment of primary open-angle glaucoma (POAG).

• These procedures may be performed as the initial treatment, when medical therapy fails, or when a patient is unable to tolerate medications.

• These laser procedures improve the outflow of aqueous humor by photocoagulation of the trabecular meshwork to lower intraocular pressure.

Sources of Information and Basis for Decision

 

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,3(98), 7. This source was used to clarify the phrase “one or more sessions”.

 

Beers, M.H., Berkow, R (Eds.). (1999). Ophthalmologic disorders: glaucoma (Section 8, Chapter 100), The Merck Manual of Diagnosis and Therapy (17th ed.). Merck &Co. Retrieved January 24, 2003 from http://www.merck.com/pubs/mmanual. This source was used to define the procedure.

 

Blyth, C., Moriarty, A., McHugh, J. (1999). Diode laser trabeculoplasty versus argon laser trabeculoplasty in the control of primary open angle glaucoma. Lasers in Medical Science, 14(2), 104-108.

 

Damji, K.F., Shah, K.C., Rock, W.J., Bains, H.S., Hodge, W.G. (1999). Selective laser trabeculoplasty v argon laser trabeculoplasty: a prospective randomized clinical trial. British Journal of Ophthalmology. Retrieved January 14,2003, from www.http://bjo.bmjjournals.com. This source was used to explain and define the procedures.

 

Hitchings, R.A (1999). Ocular surgery for the new millennium. Ophthalmology Clinics of North America. Retrieved January 15, 2003, from MD consult database http://home.mdconsult.com/das/article/body/11187101. This source was used to define methods of glaucoma management and treatment.

 

Latina, M., Tumbocon, J. (2002). Selective laser trabeculoplasty: a new treatment option for open angle glaucoma. Current Opinion in Ophthalmology, 13(2), 94-96. Retrieved April 10, 2003 from http://home.mdconsult.com/das/citation/body/jorg=journal&source=MI&sp=12345070. This source was consulted to explain and define SLT.

 

Stephenson, M. (2003). SLT to be tested as first-line therapy for open-angle glaucoma. Eyeworld, 34. Retrieved April 11, 2003, from www.eyeworld.org/mar03/0303p34.html. This reference was consulted for information regarding the SLT procedure.

 

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 L29211 Laser Trabeculoplasty