L29311-LCD

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Local Coverage Determination (LCD) for Yag Laser Capsulotomy (L29311)

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 L29311

LCD Title

Yag Laser Capsulotomy

Contractor's Determination Number 66821

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

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: CMS Manual System, Pub. 100-03, Medicare National Coverage, Chapter 1, Part 2, Section 140.5

Indications and Limitations of Coverage and/or Medical Necessity

The neodymium:YAG (Nd:Yag) laser is used to create posterior capsulotomies for posterior capsule opacification. Posterior capsule opacification generally occurs following cataract surgery. Desired outcomes of use of the Nd:Yag laser are an increase in visual acuity and/or improvement in glare and contrast sensitivity.

Medicare will consider the Nd:Yag laser capsulotomy medically necessary and reasonable if the following criteria are met:

• The patient complains of symptoms such as blurred vision, visual distortion and/or glare resulting in reduced ability or inability to carry out activities of daily living due to decreased visual acuity or an increase in glare, particularly under bright light conditions, and/or conditions of night driving.

• The eye examination confirms the diagnosis of posterior capsular opacification and excludes other ocular causes of functional impairment by one of the following methods:

- The eye examination should demonstrate decreased light transmission (visual acuity < 20/30 or < 20/25 if the procedure is performed to assist in the diagnosis and treatment of retinal detachment) after other causes of loss of acuity have been ruled out, or

- Additional testing must demonstrate 1) contrast sensitivity testing resulting in a decreased visual acuity by two

(2) lines or 2) a decrease of two (2) lines of visual acuity in the glare tester.

• This procedure should not be routinely scheduled after cataract surgery and rarely would it be expected to see this procedure performed within four months following cataract surgery. However, if a patient develops a posterior capsular opacification within four months following cataract surgery, Yag laser capsulotomy will be considered medically reasonable and necessary when the documentation demonstrates the following: the patient is experiencing symptoms of blurred vision, visual distortion, and/or glare with associated functional impairments; decreased light transmission (visual acuity < 20/30; and/or contrast sensitivity testing or glare testing resulting in a decreased visual acuity by two (2) lines.

• Occasionally, a Yag laser capsulotomy may also be performed to assist in the diagnosis and treatment of retinal detachment; to assist in the diagnosis and treatment of macular disease; to assist in the diagnosis and treatment of diabetic retinopathy; to evaluate the optic nerve head; or to diagnose posterior pole tumors.

• Generally, the Yag laser capsulotomy is expected to be performed only once per eye per lifetime of a beneficiary.

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

66821 DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)

ICD-9 Codes that Support Medical Necessity

366.50 AFTER-CATARACT UNSPECIFIED

366.51 SOEMMERING'S RING

366.53 AFTER-CATARACT OBSCURING VISION

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

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 very clearly why Yag laser capsulotomy was performed. This should include the results of a visual acuity test and/or a glare test

If procedure code 66821 is billed within four months of cataract surgery, documentation must be submitted with the claim to determine medical necessity.

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 (AAO), Anterior Segment Panel. Cataract in the adult eye. American Academy of Ophthalmology (AAO). 2001, 62 p. Retrieved October 24, 2005 from the National Guideline Clearinghouse at www.guideline.gov (002313).

Buehl, W. (2005). Association between intensity of posterior capsule opacification and visual acuity. J Cataract Refract Surg, 31(3), 543-547.

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 Original

Revision History Explanation 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 (L29311) replaces LCD L6735 as the policy in notice. This document (L29311) is effective on 02/02/2009.

Reason for Change