LCD L33630

Coverage Guidance

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 Section 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 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.

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

CMS Publications:

CMS Publication Pub. 100-08, Program Integrity Manual, Chapter 13:

13.5.1 Reasonable and Necessary Provisions in LCDs.

Indications and Limitations of Coverage

Abstract:

Corneal Pachymetry is the measurement of corneal thickness and commonly uses either ultrasonic or optical methods. Measurement of corneal thickness in individuals presenting with increased intraocular pressure assists in determining if there is a risk of glaucoma or if the individual's increased eye pressure is the result of abnormal corneal thickness. The test must be integral to the medical management decision-making of the patient. Coverage is limited to ophthalmologists and optometrists.

Indications and Limitations:

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed to determine the amount of endothelial trauma sustained during surgery, assessment of the health of the cornea pre-operatively in Fuch's dystrophy, post ocular trauma and for the assessment of corneal thickness or (in suspected glaucoma) following the diagnosis of increased intraocular pressure prior to the initiation of a treatment regimen for glaucoma. It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma or surgery.

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed only by ophthalmologist and optometrists.

Medicare will not pay for use of pachymetry when used in preparation for surgery to reshape the cornea of the eye for the purpose of correcting visual problems (refractive surgery), such as myopia (nearsightedness) and hyperopia (farsightedness).

Whether patients have been previously diagnosed and are under treatment for glaucoma or are newly diagnosed, pachymetry will be covered once per lifetime, or more frequently in cases where there has been surgical or non-surgical trauma.

When there is a question of corneal disease supported by diagnosis, then pachymetry may be performed at the same time as endothelial cell count.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Bibliography

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Albert DM, Jakobiac FA. Principles and Practice of Ophthalmology (2nd ed.) WB Saunders. 2000. (This reference was used to gain textbook knowledge of the cornea.)

Bohnke M, Mojon DS, Sobottka AC. Central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. Br. J. Ophthalmology. 2001;85:792-795.

Brandt J. Corneal thickness in glaucoma screening, diagnosis and management. Current Opinion in Ophthalmology. 2004;15:85-89.

Chen P, Kim J. Central corneal pachymetry and visual field progression in patients with open-angle glaucoma. Ophthalmology. 2004;111:2126-2132.

Herndon L, Stinnet S, Weizer J. Central corneal thickness as a risk factor for advanced glaucoma damage. Archives of Ophthalmology. 2004;122,:17-21.

Ho T, Cheng ACK, Rao SK, Lau S, Leung CKS, Lam DSC. Central corneal thickness measurements using Orbscan II, Visante, ultrasound, and Pentacam pachymetry after laser in situ keratomileusis for myopia. Ophthalmology Review. 2007;33(7):1177-1182.

Kass MA, Heuer DK, Higginbotham EJ, et al. The ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Archives of Ophthalmology. 2002;120:701-711. (This reference provided data which supported that ocular hypertension may be the result of abnormal corneal thickness.)

Kim HY, Budenz DL, Lee PS, Feuer WJ, Barton K. Comparison of central corneal thickness using anterior segment optical coherence tomography vs ultrasound pachymetry. Am J Ophthalmology. 2008;145(2):228-232.

Leung DYL, Lam KT, Yeung BYM, Lam DSC. Comparison between corneal thickness measurements by ultrasound pachymetry and optical coherence tomography. Clinical & Experimental Ophthalmology. 2006;34(8):751-754.

Medeiros FA, Sample PA, Zangwill LM, Bowd C, Aihara M, Weinreb RN. Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. American Journal of Ophthalmology. 2003;136:805-813.

Nemuesure B, Wu S, Hennis A, Leske CM. Corneal thickness and intraocular pressure in the Barbadoes eye studies. Archives of Ophthalmology. 2003;121:240-244. (This reference provided information regarding subjects determined to have increased corneal thickness and its relationship to increased ocular pressure.)

Shih C, Trokel S, Tsai J, Zivin J. Clinical significance of central corneal thickness in the management of glaucoma: Archives of Ophthalmology. 2004;122:1270-1275.

Wang J, Fonn D, Simpson TL, Jones L. Relation between optical coherence tomography and optical pachymetry measurements of corneal swelling induced by hypoxia. Am J Ohpthalmology. 2002;134(1);93-98.