JUL 09, 2021
Effective July 11, First Coast Service Options and Novitas Solutions Update Cataract Local Coverage Determination (LCD) Policies
First Coast and Novitas Update Cataract/Complex Cataract Policy effective July 11, 2021 and can be found here.
The policy impacts cataract surgeons in these states:
First Coast Service Options: Florida, Puerto Rico, Virgin Islands
Novitas: JL- Pennsylvania, New Jersey, Maryland, Delaware and the District of Columbia. JH- Texas, Oklahoma, Colorado, New Mexico, Arkansas, Louisiana, Mississippi
First Coast and Novitas have removed “Mature cataract requiring dye for visualization of capsulorrhexis” as an indication for use of complex cataract surgery. The Academy disagrees with this removal and requested First Coast and Novitas re-institute presence of a mature cataract as a covered indication for CPT 66982.
The Medicare Administrative Contractors informed the Academy that they will be moving forward with the future effective policy without revision. “The coverage of the LCD on Cataract Extraction (including Complex Cataract Surgery) will be based upon documentation that supports medical necessity and therefore covered by Medicare when one or more of the covered indications are present. The removal of the statement “Mature cataract requiring dye for visualization of capsulorrhexis” from the indications for complex cataract surgery does not preclude the coverage as complex cataract surgery of a mature cataract requiring dye for visualization of capsulorrhexis, as long as the documentation supports one or more of the covered indications. In conclusion, the use of dye in and of itself does not constitute sufficient extra work or intensity to qualify the case to be coded as complex.”
Complex cataract surgery will be considered medically reasonable and necessary when there is one of the following:
- A miotic pupil that will not dilate sufficiently requiring the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye.
- Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens.
- Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis.