Download Sample Claim Attachment

Sample Claim Attachment for ASC
Date of Service:
Patient’s Name:
Prosthetic:
Capsular Tension Ring
HCPCS Code:
L8699 – Prosthetic implant, not otherwise specified
Indications:
A capsular tension ring (CTR) is indicated for an adult patient undergoing cataract
surgery which is made more risky due to weak or partially missing zonules supporting the crystalline
lens and the capsular bag. A number of conditions can cause zonule weakness or dehiscence
including: Marfan Syndrome, Marchesani Syndrome, trauma, subluxation, prior vitrectomy, or
pseudoexfoliation of the lens.
Description:
The CTR is a sterile, non-optical ocular implant, manufactured from a single piece of
PMMA (Polymethylmethacrylate) approximately 0.2mm thick. The device is circular except where it is
interrupted by a gap with a positioning hole on either side. These holes allow the implanting surgeon to
properly position the device in the eye. CTR provides support to the capsular bag of the eye while the
surgeon inserts and stabilizes an intraocular lens during cataract surgery. The ring remains in place
after surgery.
Coverage rationale: The capsular tension ring is a prosthesis which has received FDA approval. A
prosthetic device, if furnished incident to a physician's services, is covered under Part B Medicare as
described in the Social Security Act §1832(a)(2)(I). According to the Medicare Benefit Policy Manual
Chapter 15, §260.4, prosthetic devices (other than IOLs) are not part of the ASC facility fee and are
reimbursed separately. Local Part B Medicare carriers, rather than DMERCs, are responsible for paying
claims for this prosthetic device.