Clinical UM Guideline
|Subject:||Cataract Removal Surgery for Adults|
|Guideline #:||CG-SURG-40||Current Effective Date:||07/07/2015|
|Status:||Reviewed||Last Review Date:||05/07/2015|
This document addresses cataract extraction in adults as a treatment for visually-significant cataracts, when lens removal is needed to allow better visualization of the retina or as a component of another surgical procedure. This document does not address congenital cataracts.
Note: For information concerning related topics, see:
Cataract removal surgery in adults is considered medically necessary for any of the following:
Not Medically Necessary:
Cataract removal surgery in adults is considered not medically necessary when the criteria specified above are not met, or when either of the following apply:
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|66830||Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy)|
|66840||Removal of lens material; aspiration technique, 1 or more stages|
|66850||Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration|
|66852||Removal of lens material; pars plana approach, with or without vitrectomy|
|66920||Removal of lens material; intracapsular|
|66940||Removal of lens material; extracapsular (other than 66840, 66850, 66852)|
|66982||Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic development stage|
|66983||Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)|
|66984||Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)|
|66985||Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal|
|C1780||Lens, intraocular (new technology)|
|V2630||Anterior chamber intraocular lens|
|V2631||Iris supported intraocular lens|
|V2632||Posterior chamber intraocular lens|
|Q1004||New technology intraocular lens category 4 as defined in Federal Register notice|
|Q1005||New technology intraocular lens category 5 as defined in Federal Register notice|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|13.11||Intracapsular extraction of lens by temporal inferior route|
|13.19||Other intracapsular extractin of lens|
|13.2||Extracapsular extraction of lens by linear extraction technique|
|13.3||Extracapsular extraction of lens by simple aspiration (and irrigation) technique|
|13.41||Phacoemulsification and aspiration of cataract|
|13.42||Mechanical phacofragmentation and aspiration of cataract by posterior route|
|13.43||Mechanical phacofragmentation and other aspiration of cataract|
|13.51||Extracapsular extraction of lens by temporal inferior route|
|13.59||Other extracapsluar extraction of lens|
|13.70||Insertion of pseudophakos, not otherwise specified|
|13.71||Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage|
|13.72||Secondary insertion of intraocular lens prosthesis|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|08DJ3ZZ||Extraction of right lens, percutaneous approach|
|08DK3ZZ||Extraction of left lens, percutaneous approach|
|08RJ3JZ||Replacement of right lens with synthetic substitute, percutaneous approach|
|08RK3JZ||Replacement of left lens with synthetic substitute, percutaneous approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
According to the Centers for Disease Control and Prevention (2009), cataracts are the leading cause of blindness and visual impairment, accounting for 50% of blindness representing 20.5 million (17.2%) Americans aged 40 and older. The Eye Diseases Prevalence Research Group estimates the number of individuals with cataracts is estimated to increase by 50% affecting nearly 30.1 million Americans by 2020, based on the U.S. Census population estimates (EDPRG, 2004).
Clouding of the lens of the eye is common in older persons and rarely seen in newborn children. This condition is generally known as "cataracts," but more specifically as age-related cataracts (also known as senile cataracts) or when present in previously unaffected adults and as "congenital cataracts" when present in newborn infants. Other secondary cataracts include drug-induced cataracts and traumatic cataracts. The only available treatment for cataracts at this time is surgical removal of the cataract and replacement of the affected lens with a prosthetic lens. A variety of risk factors have been associated with cataract development. The most common risk factors include diabetes mellitus (DM), long-term corticosteroid (topical, systemic or inhaled oral) use and history of prior intraocular surgeries (AAO, 2011).
The American Academy of Ophthalmology (AAO) issued guidelines for the use of cataract surgery in the adult eye in 2011, which states:
Cataract surgery should be recommended when indicated because of proven effectiveness in enhancing quality of life.
Indications for surgical management
The primary indication for surgery is visual function that no longer meets the patient's needs and for which cataract surgery provides a reasonable likelihood of improved vision. Other indications for a cataract removal include the following:
Surgery for a visually impairing cataract should not be performed under the following circumstances:
The extracapsular cataract eye (ECCE) surgical procedure is used primarily for advanced cataracts where the lens is too dense to dissolve into fragments. This procedure involves the removal of the lens nucleus in one piece with an incision of approximately 10-14 mm, leaving the capsule in place. This technique provides added support and improves the healing ability of the eye. The most commonly performed type of ECCE surgery in the United States is phacoemulsification. Phacoemulsification, a form of extracapsular cataract extraction, is also called small incision surgery, softens and breaks apart the lens using ultrasound energy and aspirated from the eye through a smaller incision (2-4 mm). After the cataract surgery is completed a foldable plastic or silicone lens may be passed through the smaller incision. The advantage of phacoemulsification technique includes a more rapid visual recovery due to the small incision size. The small incision may self-seal or require 1-2 sutures, decreasing likelihood of suture-induced astigmatism.
The intracapsular cataract eye (ICCE) surgical procedure is rarely performed in the United States. This technique involves the removal of the entire lens and surrounding capsule. It has a higher rate of complications when compared to the modern ECCE.
A Cochrane review (Riaz, 2006) describes results from a meta-analysis of seventeen trials involving 9,627 individuals randomized for surgical interventions for age-related cataracts. The authors concluded that:
Phacoemulsification gives a better outcome than ECCE with a larger wound. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.
A retrospective study by Greenberg and colleagues (2011) reported on the prevalence and predictors of ocular complications associated with cataract removal in 45,082 participants undergoing care in the Veterans Health Administration (VHA) system. Diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), age-related macular degeneration (14.4%), and diabetes with ophthalmic manifestations (14.0%) were the most common preoperative systemic and ocular comorbidities reported. Ocular complications most commonly reported among study participants included posterior capsular tear, anterior vitrectomy (or both) during surgery (3.5%) and posterior capsular opacification after surgery (4.2%). Identified predictors of complications included African- Americans, individuals who were either divorced or never married, DM with ophthalmic manifestations, traumatic cataract, and previous ocular surgery. The authors concluded "Further large studies are warranted on the prevalence and predictors of ocular complications associated with cataract surgery for United States patient populations outside the VHA, including the role of factors such as resident training and surgeon volume."
Cataract: Cloudiness of the natural lens inside the eye which can blur vision.
Cornea: The clear, transparent cover over the iris and pupil on the front part of the eye. The cornea is the first part of the eye that bends (or refracts) the light and provides most of the focusing power of the eye.
Crystalline (natural) lens: The eye's natural lens that bends light (refracts) to provide some of the focusing power of the eye. The eye's natural lens is able to change shape allowing the eye to focus at different distances.
Glaucoma: A disease characterized by destruction of the nerve fiber layer of the optic disc.
Optic nerve: The nerve that carries images of what is seen from the eye to the brain.
Retina: The light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Extracapsular cataract extraction (ECCE)
Intracapsular cataract extraction (ICCE)
|Reviewed||05/07/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Description, References and Website sections updated.|
|New||05/15/2014||MPTAC review. Initial document development.|