Local Coverage Determination (LCD)

Ophthalmic Biometry for Intraocular Lens Power Calculation

L34181

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34181
Original ICD-9 LCD ID
Not Applicable
LCD Title
Ophthalmic Biometry for Intraocular Lens Power Calculation
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 06/06/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

Annual review

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (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:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR §410.32 indicates that diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of his/her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-02, Medicare National Coverage Determinations Manual, Chapter 1, Part 1:

    10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery,

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1:

    10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 30:
220.5 Ultrasound Diagnostic Procedures

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

There are two methods used for intraocular lens power calculation:

  • A-Scan Ultrasound Ophthalmic Biometry

    Ophthalmic A-scan biometry by ultrasound echography is performed through the optical axis of the eye to determine the power of an intraocular (IOL) lens implant. The technical portion of ophthalmic biometry is usually performed in both eyes at the same setting.

  • Non-Ultrasound Ophthalmic Biometry

    Optical coherence biometry (OCB) utilizes partial coherence interferometry for measuring axial length (biometry) and for intraocular lens power calculation when planning for cataract surgery. OCB also measures the corneal curvature and anterior chamber depth. The technical portion is usually performed in both eyes at the same visit.

Indications:

Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 10.1)

Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 10.1?)

Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier’s medical staff, they are covered. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 10.1)

A second complete A scan/OCB will be covered if a different surgeon, unaffiliated with the surgeon who performed the first cataract extraction, performed the extraction on the second eye. We would not anticipate a high frequency of these instances.

Limitations:

Currently, the relative value units (RVUs) for the global and technical components of each method of ophthalmic biometry for intraocular lens power calculation are based on the procedure being bilaterally performed. If unilateral cataract extraction with an IOL implant is planned, a bilateral technical component of the A-scan or OCB is typically performed, while the professional component of the power calculation is performed unilaterally (on the operative eye only). Thus, the technical components are considered bilateral and the professional component is considered unilateral.

Prior to cataract surgery on the second, contralateral eye, allowance for the power calculation can be made. However, allowance for the technical component of the A-scan or OCB CPT code cannot be made since this bilateral procedure was performed and reimbursed at the time of the first surgery.

The technical component of the scan will generally provide valid information for twelve months. A repeat scan in less than twelve months would not be covered without documentation of significant change in vision (unless required because a second unaffiliated surgeon performed the second cataract extraction.) Generally, when bilateral cataracts are noted at examination, extraction of the second cataract is only performed after results of the first cataract extraction are known and symptoms or findings support the medical necessity for removal of the cataract in the other eye. If ophthalmic biometry is performed and later the surgery is canceled, it is reasonable to allow a repeat scan if significant time, e.g., greater than one (1) year, has elapsed when surgery is rescheduled.

Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and surgeon. If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If the biometry is repeated by the operating surgeon due to inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC. is not responsible for the continuing viability of Web site addresses listed below.

CMS National Coverage Policies

Carrier Advisory Committee

Other Medicare Contractor Local Coverage Determinations/Local Medical Review Policies, particularly Wheatlands Administrative Services, Inc., Contractor Number 00650.

Medicare Physician Fee Schedule Relative Value File/Database

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
06/06/2024 R16

R17

Revision Effective: 06/06/2024

Revision Explanation: Annual review, no changes were made.

05/31/2024 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review )
05/25/2023 R15

R16

Revision Effective: 05/25/2023

Revision Explanation: Annual review, no changes were made.

05/19/2023 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
06/02/2022 R14

R15

Revision Effective: 06/02/2022

Revision Explanation: Annual review, no changes were made.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
05/27/2021 R13

R14

Revision Effective: 05/27/2021

Revision Explanation: Annual review, no changes were made.

5/17/2021: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
12/05/2019 R12

R13

Revision Effective: n/a

Revision Explanation: Annual review, no changes made.

5/27/2020:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review, no changes)
12/05/2019 R11

R12

Revision Effective: 12/05/2019

Revision Explanation: Removed the other comments section and associated documents section and placed into the billing and coding article.

11/26/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
09/26/2019 R10

R11

Revision Effective: 09/26/2019 Revision Explanation: Converted new policy template that no longer includes coding section based on CR 10901. No changes, approval only.

09/20/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
06/06/2019 R9

R10

Revision Effective: 6-6-19 

Revision Explanation: Annual review, typographical error. Previous update did not process.

5-29-19  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other
10/01/2016 R8

R9

Revision Effective:N/A 

Revision Explanation: Annual review, typographical error.

5-6-19 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review, typographical errors updated)
10/01/2016 R7

 

R8

 

Revision Effective:N/A

 

Revision Explanation: Annual review no changes made.

 

 

 

DATE (05/31/2018): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

 

 

 

R7
Revision Effective: N/A
Revision Explanation: Annual revision no changes made

  • Other (Annual Review)
10/01/2016 R6 R
Revision Effective: 10/01/2016
Revision Explanation: During annual ICd-10 update the following codes were deleted, H40.11X0-H40.11X4 and replaced with the following codes:H40.1110, H40.1111, H40.1112, H40.1113, H40.1114, H40.1120, H40.1121, H40.1122, H40.1123, H40.1124, H40.1130, H40.1131, H40.1132, H40.1133, H40.1134.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R5 R5
Revision Effective: N/A
Revision Explanation: Annual revision no changes made
  • Other (Annual review)
01/01/2016 R4 R4
Revision Effective: 01/01/2016
Revision Explanation: POS 19 added to supplemental article. POS 19 effective 01/01/2016 for any DOS when the claim is processed on or after 01/01/2016.
  • Provider Education/Guidance
10/01/2015 R3 R3
Revision Effective: 10/01/2015
Revision Explanation: Added the following ICD-10 codes that were left off inadvertently: H25.11-H25.13, H25.091-H25.093, H40.2210-h40.2214, H40.2220-H40.2224, H40.2230-h40.2234, H40.31X0-H40.31X4, H40.32X0-H40.32X4, H40.33X0-H40.33X4, H40.41X0-H40.41X4, h40.42X0-H40.42X4, H40.43X0-H40.43X4, H40.51X0-H40.51X4
H40.52X0-H40.52X4,and H40.53X0-h40.53X4.
  • Provider Education/Guidance
10/01/2015 R2 R2
Revision Effective: 10/01/2015
Revision Explanation: Added back bill type codes that were removed in error.
  • Typographical Error
10/01/2015 R1 R1
Revision Effective: 10/01/2015
Revision Explanation: Accepted revenue code description changes.
  • Other (revenue code description)
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
05/31/2024 06/06/2024 - N/A Currently in Effect You are here
05/19/2023 05/25/2023 - 06/05/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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