CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of Ohio, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc.

Cataract Removal Surgery & Intraocular Lens Implantation (Medicare only) Policy Number: HS-100

WellCare Prescription Insurance, Inc. Windsor Health Plan Windsor Rx Medicare Prescription Drug Plan

Original Effective Date: 4/11/2013 Revised Date(s): 4/3/2014

APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs.

BACKGROUND A cataract is an opacity or cloudiness in the lens of the eye(s), blocking the passage of light through the lens, sometimes resulting in impaired vision. Cataract development occurs in 60% of adults 65 years of age or greater. There are multiple factors associated with cataract development. Some causes of cataracts may include: ultravioletβ radiation exposure, complications of diabetes, drug and/or alcohol use, smoking, and the natural process of aging. Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). (CMS, 2012). The American Academy of Ophthalmology (AAO) (2011) defines a cataract as a degradation of the optical quality of the crystalline lens and affects vision. Most cataracts are related to aging. Cataracts are very common in older people. Cataracts are the leading cause of blindness worldwide and remain an important cause of blindness and visual impairment in the United States, accounting for approximately 50% of visual impairment in adults over the age of 40. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. Cataracts are the leading cause of treatable blindness among Americans of African descent age 40 and older and are the leading cause of visual impairment among Americans of African, Hispanic/Latino, and European descent. Types of Cataracts Nuclear cataracts consist of a central opacification or coloration that interferes with visual function. There are different types of nuclear cataracts, accompanied by either brunescence, opalescence, or both. This type of cataracts tends to progress slowly and affect distance vision more than near vision. In advanced cases, the lens becomes brown and opaque. Cortical cataracts can be central or peripheral and sometimes are best visualized by retroillumination or retinoscopy. Patients commonly complain of glare. When the entire cortex becomes white and opaque, the cataract is referred to as a mature cortical cataract. Posterior subcapsular (PSC) cataracts can cause substantial visual impairment if they affect the axial region of the lens. This type of cataract is found more often in younger patients than other types. Glare, poor vision with bright lighting and near vision is more affected than distance vision. Research demonstrates that PSC cataracts are associated with the greatest rate of cataract surgery. In an older population (mean age 79 years) undergoing cataract surgery, however, nuclear cataracts were most frequently encountered. Recommendations for Care (AAO, 2012) 1. Surgery is recommended when indicated because of proven effectiveness in enhancing quality of life. 2. Surgery is recommended when indicated because of cost-effectiveness compared to other treatments. 3. The decision to recommend cataract surgery should be based on consideration of the following factors: visual acuity, visual impairment, and potential for functional benefits. 4. Cataract surgery is a procedure appropriately utilized in the United States. 5. Ophthalmologists and other physicians managing patients taking alpha-antagonists should be aware of the risks of intraoperative floppy iris syndrome (IFIS). 6. The intraocular pressure (IOP) lowering effect of cataract surgery should be considered in the overall management of the patient. Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

7. Ophthalmologists should be aware of increased antibiotic resistance in the general population. 8. The optimum dosing and route of administration of antibiotics should be considered in order to achieve a high intraocular concentration immediately following surgery. 9. Although the incidence is rare, ophthalmologists should be aware of the potential risk of toxic anterior segment syndrome (TASS). 10. Absent a normal capsular bag, ophthalmologists should determine whether the power and design of an intra-ocular lens (IOL) intended for capsular bag fixation is or is not appropriate for ciliary sulcus placement. 11. Safety protocols should be in place to prevent the occurrence of wrong-site surgery. Recommended Examination Components    

Patient history including an assessment of visual function status and interference with activities of daily living (ADLs) and/or occupation. Specific complaints pertaining to blurred and/or decreased vision. Identification of other causes for decreased visual acuity (which should be documented). Demonstration of retinal potential.

Intraocular Lens Implant An Intraocular lens (IOL) implant consists of a small, clear, plastic lens which can replace a member’s natural lens after it has been removed. Used to improve vision, IOLs are often placed after cataract surgery. The IOL becomes permanent and is unable to be felt or seen. Four types of IOLs are commonly used: 1. Monofocal are a single, fixed length lens and for distance vision only. Reading glasses are often needed after an implant is inserted. Types of monofocal IOLs include (but are not limited to) Akreos™, CeeOn™ Edge Model 911A, PAL™, Softec HD™, and iSpheric™ Model YA-60BB. 2. Multifocal are lenses for near and distant vision. Types of multifocal IOLs include (but are not limited to) AcrySof® ReSTOR®, ReZoom®, and Tecnis® Model ZM900 and ZMA00. 3. Accommodating (accommodative) are said to duplicate the accommodation of the natural lens and known as presbyopia correcting lenses. A common types of multifocal IOLs includes (but is not limited to) the Crystalens™ Model AT-45. 4. Ultraviolet Light Absorbing lenses consist of a special polymeric material that absorbs ultraviolet light as well as blue light (short wavelength) which is said to improve vision clarity. Options include monofocal or multifocal. Types of multifocal IOLs include (but are not limited to) C-Flex™, Allergan Model AC21B, and the XACT® Model X-60 and X-70. POSITION STATEMENT Applicable To: Medicaid Medicare

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

Cataract Removal Surgery The CMS guidelines require a documented best corrected visual acuity of 20/50 or worse and a subjective complaint of impairment of lifestyle. Or, if the visual acuity is correctable to 20/40 or better, document a decrease in visual acuity by a glare test, or Brightness Acuity Test (BAT) to 20/50 or worse. Intraocular Lens Implants (IOLs) are the standard of care following cataract extraction surgery. The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:       

Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; AND, The patient has determined that he/she is no longer able to function adequately with the current visual function; AND, Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; AND, Significant improvement in visual function can be expected as a result of cataract extraction; AND, The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); AND, The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry; AND, The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following: o Consensual light testing decreases visual acuity by two lines; OR, o Glare testing decreases visual acuity by two lines.

Cataract extraction may be covered when an unimpeded view of the fundus is mandatory for proper management of patients with diseases of the posterior segment of the eye(s). Cataract extraction may be covered during vitrectomy procedures if it is determined that the lens interferes with the performance of the surgery for far peripheral vitreoretinal dissection and excision of the vitreous base, as in cases of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy. For patients with a best corrected visual acuity of 20/40 or better, cataract extraction will be considered if all other criteria have been met and there is substantial documentation of the medical necessity of the procedure for that patient. Cataract removal surgery is considered medically necessary and a covered benefit when one of following three criterion below are met: 1. A member must have a visual disability including a Snellen Acuity of 20/50 or worse or a Snellen Acuity of 20/40 or better with the following conditions: 

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A member is unable to maintain necessary activities of daily living (ADLs) due to visual impairment. Assessment can include driving, watching television, and needs related to work as well as a member with difficulty with near sighted activities (e.g., reading, work-related) and a loss of independence and/or income. Visual acuity in the affected eye is 20/50 or worse as detected by Snellen visual acuity and an eye examination confirms the cataract is responsible for limiting visual function when other factors do not preclude improvement following surgery, and the member's medical and mental health permits surgery to be performed safely. Providers educate a member concerning risks and benefits of surgery; discussion should include treatment alternatives and the member can determine if the reduction in visual disability outweighs the potential risk, cost and inconvenience of surgery.

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

NOTE: A drop in visual acuity in bright light is the quantitative element that allows one to correlate the "loss of vision" with the "member's complaints". The most common cataract that produces this type of light-related visual loss is a centrally located posterior subcapsular plaque (PSCP).

OR; 2. A member with only one eye must demonstrate that the cataract has caused a visual disability of 20/80 or worse. This includes a member with legal blindness (20/200 or worse) in the other eye. OR; 3. Surgery and removal of the lens is medically necessary without visual disability when the following are met:  A member has a lens disease such as phacomorphic glaucoma, phacolytic glaucoma, phacoanaphylactic endophthalmitis, or dislocated or subluxated lens; OR;  The need to visualize the fundus in order to monitor or treat an ocular condition; OR;  The retina must be visualized in an eye with the potential of vision due to any of the following: o Diabetes with risk of diabetic retinopathy that requires photocoagulation management via clear media as a means of monitoring glaucoma; o Preparation for vitrectomy; o Preparation for surgery to repair retinal detachment; o When it a need is demonstrated for intra-ocular pathology, requiring clear media. OR; 4. Symptomatic anisometropia of three (3) diopters or greater induced by changes in the natural lens, not intentionally created by cataract surgery. Note: If the anisometropia is intentionally created by surgery and the fellow eye has no cataract or a visually insignificant cataract, then surgery upon that eye will be considered refractive in nature and will not be covered. NOTE: A comprehensive eye examination to include a diagnostic A-mode ultrasound (A-scan) prior to surgery may be necessary.

Bilateral Extraction If the decision to perform cataract extraction in both eyes is made prior to the first cataract extraction, the documentation must support the medical necessity for each procedure to be performed. Bilateral cataract extraction should not be performed on both eyes on the same day because of the potential for bilateral visual loss. If the first cataract extraction is performed and a subsequent contralateral cataract extraction is considered, the criteria for coverage of the procedure in the contralateral eye are the same as the criteria for the first cataract extraction. (CMS, 2012). Complex Cataract Surgery CPT 66982 for complex cataract surgery is intended to differentiate the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations including (but not limited to) (CMS, 2012): 

A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and which requires the insertion of four (4) iris retractors through four (4) additional incisions, Beechler or similar expansion device, a sector iridectomy with subsequent suture repair of iris sphincter,synechialysis tuilizing papillary stretch maneuvers or sphincterotomies created with scissors.

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The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures and/or a capsular

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

support ring (approved by the FDA) may be necessary to allow placement of an intraocular lens. 

Pediatric cataract surgery may be more difficult intraoperatively because of an anterior capsule which is more difficult to tear, cortex which is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorhexis. Additional postoperative work is associated with pediatric cataract surgery.

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Extraordinary work may occur during the postoperative period. This is the case with pediatric cases mentioned above and very rarely when there is extreme postoperative inflammation and pain.

In addition, CPT 66982 requires one of the following:  Mature cataract* requiring capsule staining for visualization; OR;  Continuous use of a tension ring or iris expansion device during the procedure; OR;  The placement of iris retraction hooks utilized throughout the cataract removal procedure. *NOTE: A mature cataract is one in which there is no clear cortex detectable beneath the anterior capsule and the best corrected vision is “hand motion” or worse.

Visual Tests Prior to and General Anesthesia During Cataract Surgery Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented. Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier's medical staff, they are covered. The use of general anesthesia in cataract surgery may be considered reasonable and necessary if, for particular medical indications, it is the accepted procedure among ophthalmologists in the local community to use general anesthesia. (CMS, 1992). The following ophthalmologic services are considered medically necessary prior to surgery when indicated due to other ophthalmological conditions:  Optical coherence biometry  Ultrasound, A-scan, diagnostic  Ultrasound, A-scan, ophthalmic biometry  Ultrasound, with intra-ocular lens (IOL) power calculation. NOTE: A-mode ultrasound (A-scan) may be considered medically necessary to assess the pseudophakic power of the IOL. Prior authorization is not needed for A-scan. NOTE: Results of B.A.T. testing are not acceptable, except in the case of posterior subcapsular cataracts and cortical spokes in the visual axis, as pre-operative indications for cataract surgery.

Experimental / Investigational Indications The following are considered experimental / investigational and not a covered benefit unless determined for another indication due to a lack of efficacy for routine evaluation prior to cataract surgery:  Contrast sensitivity testing  Corneal pachymetry  Corneal topography  Electrophysiologic tests  External photography  Fluorescein angiography Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

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Formal visual fields Glare testing or disability Potential vision testing Specialized color vision tests Specular photographic microscopy Ultrasound, contact B-scan, diagnostic* Ultrasound, immersion B-scan, diagnostic* Visual evoked potentials.

NOTE: B-scan ultrasound is considered medically necessary in place of A-scan ultrasound when a member has a dense cataract.

Inpatient Cataract Surgery Inpatient cataract removal surgery is typically not medically necessary. In the event a patient cannot have outpatient surgery, the following medical necessity should be followed:     

Additional medical conditions require prolonged post-operative observation by a nurse or other skilled personnel and the member requires general medical and nursing care for a particularly complex ocular procedure(s); OR; Multiple ocular conditions are present (e.g., best correctable vision in the non-operated eye is 20/200 or worse); OR; Member needs multiple ocular procedures (e.g., medical circumstances exist that make having to undergo anesthesia twice may be dangerous or life-threatening and dual cataract removal is performed); OR; Risk of injury exists during the immediate post-operative period due to a member being mentally debilitated or diagnosed with a mental illness, or is otherwise functionally incapacitated. Successful post-operative care is not likely in an outpatient setting due to member’s physical disability.

Intraocular Lens Implants Monofocal IOL implants are a covered benefit when a member has at least one of the following conditions:     

A damaged lens due to trauma to the eye; OR; A congenital cataract; OR; Congenital aphakia; OR; Lens subluxation/displacement; OR; Anisometropia of > 3 diopters and uncorrectable vision with the use of glasses or contact lenses.

In addition, for member’s having cataract removal surgery, IOL implants must be inserted during removal of member’s natural lens during cataract surgery. If bilateral removal is being done along with IOL implants, cataract removal surgery should be done on one eye at a time in order to allow sufficient healing time (typically 2 to 6 weeks). For member’s undergoing non-cataract related surgery, IOL must be placed during surgery, and should not be performed on both eyes on the same day because of the potential for visual loss. Monofocal IOL implants are not medically necessary or a covered benefit for the following:  

Premium IOL implant for any condition, including aphakia. Such implants reduce the need for reading glasses – this is not considered medically necessary as it is a convenience. Lenses that correct a refractive error – these include (but are not limited to): o presbyopia correcting IOL such as Array® Model SA40, ReZoom™,, AcrySof® ReStor® ,Tecnis

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

o o

ZM900, Crystalens™ Model AT-45, Crystalens HD™, and Crystalens Aspheric Optic™. astigmatism correcting IOL (Toric IOLs) phakic IOL (ARTISAN®, STAR Visian ICL™)

Visual Tests Prior to and General Anesthesia During IOL Implantation Surgery (CMS, 1992) Cataract surgery with an intraocular lens (IOL) implant is should include a substantial number of preoperative tests that are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used. CODING Covered CPT®* Codes 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 developmental 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 techniques (eg, irrigation and aspiration or phacoemulsification) CPT®* Modifiers RT Right Right side (used to identify procedures performed on the right side of the body LT Left Left side (used to identify procedures performed on the left side of the body 50 Bilateral Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. HCPCS Codes C1780 Lens, intraocular (new technology C1840 Lens, intraocular (telescopic) V2630 Anterior chamber intraocular lens V2631 Iris supported intraocular lens V2632 Posterior chamber intraocular lens ICD-9-CM Procedure Code 13.2 Extracapsular extraction of lens by linear extraction technique 13.3 Extracapsular extraction of lens by simple aspiration (and irrigation) technique 13.41 Extracapsular extraction of lens by fragmentation and aspiration technique 13.42 Mechanical phacofragmentation and aspiration of cataract by posterior route 13.43 Mechanical phacofragmentation and other aspiration of cataract 13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage Covered ICD-9-CM Diagnosis Code 366.00 – 366.9 Cataract 743.30 – 743.35 Congenital cataract 379.32 - 379.39 Lens subluxation/displacement 367.31 Anisometropia

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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CATARACT REMOVAL SURGERY & INTRAOCULAR LENS IMPLANTATION HS-100

Covered ICD-10-CM Diagnosis Codes H25-H28 Disorder of lens Q12 Congenital lens malformations *Current Procedural Terminology (CPT) 2014 American Medical Association: Chicago, IL.®©

REFERENCES Government Agencies, Professional and Medical Organizations 1. American Academy of Ophthalmology. (2011). Preferred practice pattern guidelines: cataract in the adult eye. Retrieved from http://one.aao.org/ce/practiceguidelines/ppp_content.aspx?cid=a80a87ce-9042-4677-85d74b876deed276 2. Centers for Medicare and Medicaid Services. (2012, October 1). Local coverage determination for cataract extraction (L31860). Retrieved from http://www.cms.hhs.gov/mcd/search.asp 3. Centers for Medicare and Medicaid Services. (1992, August 31). National coverage determination for use of visual tests prior to and general anesthesia during cataract surgery (10.1). Retrieved from http://www.cms.hhs.gov/mcd/search.asp MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date

Action

4/3/2014 4/11/2013

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Approved by MPC. No changes. Approved by MPC. New guideline.

Clinical Coverage Guideline Original Effective Date: 4/11/2013 - Revised:4/3/2014

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