LCD L37644

Coverage Guidance

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

Indications and Limitations of Coverage

Neodymium-doped Yttrium Aluminum Garnet (YAG) laser capsulotomies are performed in cases of opacification of the posterior capsule, generally no less than 90 days following cataract extraction. YAG performed less than 90 days following cataract extraction should meet both the indications and limitations of this Local Coverage Determination (LCD). The percentage of patients having this procedure varies greatly among ophthalmologists. Diagnosis of functional visual impairment due to capsular opacification is based on clinical judgment regarding 1 or more of the following:

• Visual loss and/or symptom of glare (visual acuity 20/30 or worse under Snellen conditions, using contrast sensitivity, or simulated glare testing);

• Symptoms of decreased contrast;

• Amount of posterior capsular opacification or;

• Other possible causes of decreased vision following cataract surgery.

Limitations

This procedure will not be covered within 3 months post cataract surgery unless justified by 1 of the following indications:

• Posterior capsular plaque/opacity which cannot be safely removed during primary phacoemulsification cataract procedure

• Capsular block during which cataract remnants and fluid become trapped within the lens capsule and addressed with YAG laser posterior capsulotomy

• Contraction of the posterior capsule with displacement of the intraocular lens.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

• All coverage criteria must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

• The justification for a YAG capsulotomy procedure performed less than 3 months after cataract surgery, as described in the Limitations section of this LCD, should be clearly documented in the medical record.

Bibliography

American Academy of Ophthalmology. Cataract in the Adult Eye, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2016. Accessed 2/1/22.