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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.