L29211-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Laser Trabeculoplasty (L29211)

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 L29211

LCD Title

Laser Trabeculoplasty

Contractor's Determination Number 65855

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 N/A

Indications and Limitations of Coverage and/or Medical Necessity

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.

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.

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

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

365.4 OCULAR HYPERTENSION

365.5 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

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

Documentation such as the patient’s medical record should demonstrate the medical necessity for the Argon Laser Trabeculoplasty (ALT), Selective Laser Trabeculoplasty (SLT), or 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.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

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.

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 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

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

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Revised descriptor for diagnosis code 365.01. Added new diagnosis code 365.05. The effective date of this revision is 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 (L29211) replaces LCD L13840 as the policy in notice. This document (L29211) is effective on 02/02/2009.

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change