Download Cataract Extraction-Second Eye

ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 1 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
IMPORTANT REMINDER:
This Clinical Policy has been developed by appropriately experienced and
licensed health care professionals based on a thorough review and consideration
of generally accepted standards of medical practice, peer-reviewed medical
literature, government agency/program approval status, and other indicia of
medical necessity.
The purpose of this Clinical Policy is to provide a guide to medical necessity.
Benefit determinations should be based in all cases on the applicable contract
provisions governing plan benefits (“Benefit Plan Contract”) and applicable state
and federal requirements including Local Coverage Determinations (LCDs), as
well as applicable plan-level administrative policies and procedures. To the
extent there are any conflicts between this Clinical Policy and the Benefit Plan
Contract provisions, the Benefit Plan Contract provisions will control.
Clinical policies are intended to be reflective of current scientific research and
clinical thinking. This Clinical Policy is not intended to dictate to providers how
to practice medicine, nor does it constitute a contract or guarantee regarding
results. Providers are expected to exercise professional medical judgment in
providing the most appropriate care, and are solely responsible for the medical
advice and treatment of members.
SUBJECT:
Medical necessity determination of second eye cataract extraction with or
without insertion of intraocular lens (IOL).
DESCRIPTION:
A cataract is any opacity of the lens whether it is a small local opacity or a
diffuse general loss of transparency. To be clinically significant, the cataract
must cause a significant reduction in visual acuity or functional impairment.
Cataracts may occur as a result of aging or secondary to heredity factors,
trauma, inflammation, metabolic or nutritional disorders, or radiation. Agerelated cataracts are the most common. As a guideline for Envolve Vision, the
definition of a cataract is an opacification of the lens that leads to measurably
decreased visual acuity and/or functional disability as perceived by the patient.
Classifications for the three most common types of cataracts are defined below:
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 2 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
1. Nuclear sclerotic cataract (NSC) is the most common type, especially in the
elderly, with yellowing and sclerosis of the lens nucleus that gradually
causes a decrease in vision.
2. Posterior subcapsular cataract (PSC) typically involves a central white
haziness in the posterior aspects of the lens. When this type of cataract is
within the visual axis, symptoms can be prominent and disabling. These
cataracts can progress rapidly over a short period of time.
3. Cortical cataracts (CC) usually involve cuneiform or spoke-like white
opacities. When these opacities approach the visual axis, symptoms of
decrease in vision and glare can be significant.
POLICY/CRITERIA:
• Cataract surgery requires pre-authorization for selected health plans.
Envolve Vision will consider pre-authorization for cataract surgery for one eye
at a time; relying, in part, on the indications for cataract surgery as
enumerated by the Centers for Medicare and Medicaid Services (CMS) and the
Preferred Practice Patterns of the American Academy of Ophthalmology.
• Cataract surgery is indicated when there is a complaint of blurred vision and
meaningful functional impairment due to cataract. When the best corrected
visual acuity is 20/50 or worse due to cataract, then functional impairment
will be assumed.
• Surgery should not be performed in both eyes at the same time because of
potential for bilateral visual loss. Requests for bilateral cataract surgery or
bilateral sequential cataract surgery will not be approved. Providers must
request cataract surgery one eye at a time.
• A comprehensive ophthalmic evaluation, including manifest refraction
documenting the medical necessity for cataract surgery must be done no
longer than three months prior to surgery for either eye. Automated
refractors/refractions are not equivalent to or billable as a manifest
refraction, and cannot be used to determine best corrected visual acuity.
• Consideration of the appropriate intervals between the first-eye surgery and
second-eye surgery is influenced by several factors:
o The patient’s visual needs
o The patient’s preferences
o Visual acuity or function of the second eye
o The medical and refractive stability of the first eye
o The need to develop binocular vision
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 3 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
•
•
•
•
•
•
•
•
o Symptomatic anisometropia
o Logistical concerns of the patient in traveling back and forth to the
physician’s office
The patient and the ophthalmologist should discuss the benefits, risks, and
timing of the second-eye surgery when they have an opportunity to evaluate
the results of the surgery on the first eye.
Prior to performing surgery on the second eye, the patient’s first eye should
have a stable post-operative manifest refraction and the patient should
perceive improved function.
The patient needs sufficient time to assess the results of the first-eye surgery
to determine the need and appropriate timing for the surgery on the second
eye. Sufficient time should have elapsed to evaluate and treat early
postoperative complications.
Envolve Vision Utilization Management requests that patients who are
proposed for bilateral cataract surgery have the worst eye operated on first
and be evaluated (during the postoperative period) by the surgeon for totality
of healing and level of functioning, as detailed above.
Envolve Vision, consistent with the Preferred Practice Patterns of the
American Academy of Ophthalmology, recommends that all patients have
their best manifest refraction dispensed after first-eye cataract surgery. This
will allow patients to assess their visual outcome in a best-corrected state
(OU) before proceeding immediately with an elective procedure in the contralateral eye (Medicare provides for a vision hardware benefit after cataract
surgery in either eye).
If persistent visual difficulties are noted after the patient has received a bestcorrected refraction and glasses prescribed, then consideration can then be
given for proceeding with surgery in the contra-lateral eye.
Envolve Vision considers contrast sensitivity and/or glare results indicating a
reduction in visual acuity on low or medium intensity as additional
documentation of medical necessity.
Use of multifocal implants - The use of multifocal implants in a patient does
not necessarily require that Envolve Vision cover the service of cataract
surgery in the second eye which does not contain a cataract that is causing a
meaningful functional impairment. The use of multifocal lenses in a patient
should prompt a thorough discussion between the operating surgeon and the
patient with regards to the probable need for bilateral implantation. If the
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 4 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
•
2nd eye does not meet Envolve Vision cataract criteria then the patient
should be counseled that out-of-pocket expenses will be necessary for 2nd
eye lens (exchange) surgery.
When the indication for second eye surgery is anisometropia, the degree of
difference should be greater than or equal to 3.00 diopters. Requests for
surgery with less than 3.00 diopters anisometropia will be considered if
appropriate documentation in the chart indicates the patient has undergone
bilateral manifest refraction and the imbalance is intolerable.
AUTHORIZATION PROTOCOLS:
Cataract extraction requires pre-authorization in selected markets.
Professional services provided by duly licensed eye care providers must be within
the scope of licensure as defined by applicable State guidelines.
•
•
•
All pre-authorization requests should include a reasonable expectation of
improved visual functional ability. If previous cataract extraction has been
performed on the other eye, current visual acuity in the postoperative eye
should be documented and submitted with the request.
If none of the preceding criteria are present, the request is to be referred to
the Medical Director for review. With glare or bright light acuity testing, the
patient’s best-corrected visual acuity should be 20/40 or worse. The Medical
Director may request a second opinion delineating the necessity for surgery.
The Medical Director may request a VF-14 questionnaire will determine the
necessity of the surgery based on the medical criteria and VF-14 score. All
requests for cataract surgery will be pre-authorized as outpatient unless
otherwise directed by the Medical Director.
Review of office medical records will include the following guidelines:
a. An ocular examination must be performed in the office within three
months prior to the planned surgery. The exam should include the
following elements and the information as defined in the Medical Review
Criteria for cataract surgery with complete documentation in the patient’s
chart:
− Patient history including patient’s assessment of functional status
− Best-corrected Snellen acuity and manifest refraction
− Measurement of intra-ocular pressure
− Assessment of pupillary function
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 5 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
− External examination
− Slit lamp examination including grading of cataract
− Dilated examination of the fundus
b. The patient should have a general medical history and physical
examination as deemed appropriate for the planned anesthesia and
surgery with complete documentation in the chart.
c. The postoperative examination should contain the following elements:
− Assessment of visual functions with each visit
− Measurement of intra-ocular pressure with each visit
− Slit lamp examination with each visit
− Define a management plan with each visit
− In the absence of improved visual acuity, history should be taken
directly from the patient in order to assess the impact of the surgery
on the patient’s vision, function, and activities
− A dilated exam of the fundus to include the peripheral retina should
be performed at least once during the postoperative period,
preferably within 90 days to 6 months from date of surgery
− If surgery postoperative care is being co-managed between an
ophthalmologist and an optometrist, both should share the
responsibility of the dilated exam as well as entire postoperative
procedure (the optometrist should provide the surgeon with updates
on the patient’s follow-up care)
REFERENCES:
National Government Services, Inc. Local Coverage Determination L33558
Cataract Extraction, Massachusetts, Revised 10/1/2015
Noridian Healthcare Solutions, LLC Local Coverage Determination L34203
Cataract Surgery in Adults, Northern California, Revised 10/1/2015
Novitas Solutions, Inc. Local Coverage Determination L34344 Cataract
Extraction, Louisiana, Revised 10/1/2015
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 6 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
American Academy of Ophthalmology (AAO) and American Society of Cataract
and Refractive Surgeons (ASCRS) Guidelines for Billing Medicare Beneficiaries
When Using the Femtosecond Laser
ATTACHMENTS:
Attachment A – ICD-9 / ICD-10 Code Crosswalk
CODING IMPLICATIONS:
Envolve Vision’s allowable reimbursement for cataract surgery does not change
according to the surgical methods used. For example, the reimbursement is the
same whether a cystotome or femtosecond laser makes the capsulotomy. Extracapsular cataract extraction is reimbursed the same as phacoemulsification.
Providers may not balance bill a patient or his/her secondary insurer for any
additional fees based on the technology used for the covered procedure.
Envolve Vision provides reimbursement for cataract extraction (66984 or 66982)
with or without insertion of IOL one time per member per eye per lifetime.
Envolve Vision permits patients to be billed for additional services used
specifically to implant premium refractive IOLs (presbyopia-correcting and toric)
for medically-necessary cataract. The surgeon and facility may charge the
patient for premium refractive IOLs (presbyopia-correcting and toric) and the
associated incremental professional and technical services. The patient, however,
must be informed about, and consent to, the additional out-of pocket-costs in
advance.
Refractive Lens Exchange
A refractive lens exchange is not medically necessary and therefore is not
covered by Envolve Vision. The surgeon and the facility may bill the patient.
Medically-Necessary Cataract Extraction with a Conventional IOL (No astigmatic
keratotomy)
Envolve Vision covers the cataract surgery and the implantation of a
conventional IOL without regard to the technology used. A surgeon may use the
FS laser for the cataract surgery, but neither the surgeon nor the facility may
obtain additional reimbursement from either Envolve Vision or the patient over
and above the allowable amount.
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 7 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
Medically-Necessary Cataract Extraction with a Premium Refractive IOL (No
astigmatic keratotomy)
Neither the surgeon nor the facility should use the differential charge allowed for
implantation of a premium refractive IOL to recover all or a portion of the costs
of using the FS laser for cataract surgical steps. As set forth above, Envolve
Vision covers the cataract surgery and the implantation of a conventional lens
without regard to the technology used. Patient-shared pricing with one cost for a
premium IOL, and a higher cost for the additional use of the FS laser to perform
the cataract surgical steps, should not be offered. This would amount to
charging the patient to use the FS laser to perform covered components of the
procedure.
Medically-Necessary Cataract Surgery Plus Astigmatic Keratotomy Performed for
Refractive Indications
Envolve Vision will cover medically-necessary cataract surgery, but not
concurrent correction of astigmatism performed for refractive indications.
Envolve Vision patients may be charged a fee for performing astigmatic
keratotomy, assuming that they were informed about, and consented to, the
non-covered charges in advance. As with premium IOLs, however, the patient
should not be charged an additional amount to concurrently perform the
cataract surgical steps with the FS laser. While most astigmatism treatment is
not covered, Envolve Vision does cover the treatment of large degrees of
astigmatism that were the result of previous ocular surgery. Local coverage
determinations may apply. In this situation, neither the surgeon nor the facility
may obtain additional reimbursement from either Envolve Vision or the patient
over and above the allowable amount.
ICD-10 Code
E08.36
E09.36
E10.36
E11.36
E13.36
ICD-10 Code Description
Diabetes mellitus due to underlying condition with diabetic
cataract
Drug or chemical induced diabetes mellitus with diabetic cataract
Type 1 diabetes mellitus with diabetic cataract
Type 2 diabetes mellitus with diabetic cataract
Other specified diabetes mellitus with diabetic cataract
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 8 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
H25.011
H25.012
H25.013
H25.031
H25.032
H25.033
H25.041
H25.042
H25.043
H25.091
H25.092
H25.093
H25.11
H25.12
H25.13
H25.21
H25.22
H25.23
H25.811
H25.812
H25.813
H25.89
H25.9
H26.001
H26.002
H26.003
H26.011
H26.012
H26.013
H26.031
Cortical age-related cataract, right eye
Cortical age-related cataract, left eye
Cortical age-related cataract, bilateral
Anterior subcapsular polar age-related cataract, right eye
Anterior subcapsular polar age-related cataract, left eye
Anterior subcapsular polar age-related cataract, bilateral
Posterior subcapsular polar age-related cataract, right eye
Posterior subcapsular polar age-related cataract, left eye
Posterior subcapsular polar age-related cataract, bilateral
Other age-related incipient cataract, right eye
Other age-related incipient cataract, left eye
Other age-related incipient cataract, bilateral
Age-related nuclear cataract, right eye
Age-related nuclear cataract, left eye
Age-related nuclear cataract, bilateral
Age-related cataract, morgagnian type, right eye
Age-related cataract, morgagnian type, left eye
Age-related cataract, morgagnian type, bilateral
Combined forms of age-related cataract, right eye
Combined forms of age-related cataract, left eye
Combined forms of age-related cataract, bilateral
Other age-related cataract
Unspecified age-related cataract
Unspecified infantile and juvenile cataract, right eye
Unspecified infantile and juvenile cataract, left eye
Unspecified infantile and juvenile cataract, bilateral
Infantile and juvenile cortical, lamellar, or zonular cataract, right
eye
Infantile and juvenile cortical, lamellar, or zonular cataract, left eye
Infantile and juvenile cortical, lamellar, or zonular cataract,
bilateral
Infantile and juvenile nuclear cataract, right eye
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 9 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
H26.032
H26.033
H26.041
H26.042
H26.043
H26.051
H26.052
H26.053
H26.061
H26.062
H26.063
H26.09
H26.101
H26.102
H26.103
H26.111
H26.112
H26.113
H26.121
H26.122
H26.123
H26.131
H26.132
H26.133
H26.20
H26.211
H26.212
H26.213
H26.221
Infantile and juvenile nuclear cataract, left eye
Infantile and juvenile nuclear cataract, bilateral
Anterior subcapsular polar infantile and juvenile cataract, right eye
Anterior subcapsular polar infantile and juvenile cataract, left eye
Anterior subcapsular polar infantile and juvenile cataract, bilateral
Posterior subcapsular polar infantile and juvenile cataract, right
eye
Posterior subcapsular polar infantile and juvenile cataract, left eye
Posterior subcapsular polar infantile and juvenile cataract, bilateral
Combined forms of infantile and juvenile cataract, right eye
Combined forms of infantile and juvenile cataract, left eye
Combined forms of infantile and juvenile cataract, bilateral
Other infantile and juvenile cataract
Unspecified traumatic cataract, right eye
Unspecified traumatic cataract, left eye
Unspecified traumatic cataract, bilateral
Localized traumatic opacities, right eye
Localized traumatic opacities, left eye
Localized traumatic opacities, bilateral
Partially resolved traumatic cataract, right eye
Partially resolved traumatic cataract, left eye
Partially resolved traumatic cataract, bilateral
Total traumatic cataract, right eye
Total traumatic cataract, left eye
Total traumatic cataract, bilateral
Unspecified complicated cataract
Cataract with neovascularization, right eye
Cataract with neovascularization, left eye
Cataract with neovascularization, bilateral
Cataract secondary to ocular disorders (degenerative)
(inflammatory), right eye
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 10 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
H26.222
H26.223
H26.231
H26.232
H26.233
H26.31
H26.32
H26.33
H26.40
H26.411
H26.412
H26.413
H26.491
H26.491
H26.492
H26.493
H26.8
H26.9
H28
Cataract secondary to ocular disorders (degenerative)
(inflammatory), left eye
Cataract secondary to ocular disorders (degenerative)
(inflammatory), bilateral
Glaucomatous flecks (subcapsular), right eye
Glaucomatous flecks (subcapsular), left eye
Glaucomatous flecks (subcapsular), bilateral
Drug-induced cataract, right eye
Drug-induced cataract, left eye
Drug-induced cataract, bilateral
Unspecified secondary cataract
Soemmering's ring, right eye
Soemmering's ring, left eye
Soemmering's ring, bilateral
Other secondary cataract, right eye
Other secondary cataract, right eye
Other secondary cataract, left eye
Other secondary cataract, bilateral
Other specified cataract
Unspecified cataract
Cataract in diseases classified elsewhere
REVIEW/REVISION LOG
Revision:
Clarification of indications for cataract surgery.
Clarification of manifest refraction requirements.
Update to references and corporate name
Update to references
Annual review
Converted SOP to new format, changed Reference Number to
comply with new SOP numbering policy.
Addition of criteria for second eye due to anisometropia.
Date
05/2016
04/2016
12/2015
12/2014
12/2013
08/2012
08/2012
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.
ENVOLVE VISION BENEFITS, INC.
INCLUDING ALL ASSOCIATED SUBSIDIARIES
CLINICAL POLICY AND PROCEDURE
DEPARTMENT: Utilization
DOCUMENT NAME: Cataract Extraction
Management
Criteria, Second Eye
PAGE: 11 of 11
REFERENCE NUMBER: OC.UM.CP.0009
EFFECTIVE DATE: 01/01/2016
REPLACES DOCUMENT: 127-UM-R8
RETIRED:
REVIEWED: 05/23/2016
SPECIALIST REVIEW: Yes
REVISED: 05/23/2016
PRODUCT TYPE:
COMMITTEE APPROVAL: 04/11/2016
Addition of statement that OMV/TVHP follows local Medicare
criteria.
Addition of criteria that a comprehensive ophthalmic evaluation
must be completed no more than 3 months prior to surgery for
either eye
Revision of policy statement, criteria and process for preauthorization of cataract surgery for the second eye
Policy renumber; formatting changes
Annual review/revision
Addition of contrast sensitivity as a consideration for medical
necessity
Renumbered policy
05/2010
11/2007
02/2006
02/2005
02/2004
02/2003
02/2002
These are Confidential and Proprietary materials of Envolve Vision Benefits, Inc. Options (Envolve Vision), which
should not be reproduced in any manner or shared with any third party without the prior written consent of
Envolve Vision.