Search Result - JF Part B

Noridian's Response to Provider Recommendation (for comment period ending 11/3/2014)

Comment 1:
Reconstructive procedures should be directed at structures with abnormal anatomy.
Response 1:
The policy has been amended so as not to formally address reconstructive procedures. Clarifying language has been added and appropriate deletions (including applicable CPT and ICD-9 [ICD-10 in appropriate versions] codes) have been made.

Comment 2:
Functional criteria for coverage and surgery to correct it should have an anatomic basis.
Response 2:
It is believed the policy, after clarifications related to reconstructive surgery, has an anatomic basis for those entities that remain the subject of the LCD.

Comment 3:
Photos but no visual fields contradict the primary requirement of the policy.
Response 3:
The intent of the policy was to offer clear criteria that can be cogently explained to a patient and uniformly evaluated by reviewers. The MRD criterion has been selected such that for a given patient it would correspond (based on lid position) to a visually-significant field cut (to approximately 30 degrees or less) in the presence of an acceptable patient complaint. Visual fields can be performed to demonstrate to the patient that they might improve or if dictated by the standard of care, but are subject to wide variation and therefore considered unreliable for the purposes of this policy. In the expected to be rare circumstances where a patient would fail the MRD1 criterion but the provider feels that visual field testing would, despite that fact, support performance of surgery for a functional reason, this can be considered on appeal. Note also that similar criteria in Jurisdiction E (previously Jurisdiction 1) in place for several years before this revision for the purpose of establishing uniformity within Jurisdictions covered by Noridian Healthcare Services did not result in detectable increases in inappropriately performed surgeries addressed by the policy.

Comment 4:
Subjective criteria should be substantiated by multiple objective data points.
Response 4:
It is believed the policy as revised evaluates adequate objective data to provide clear covered/not covered determinations.

Comment 5:
Marginal reflex distance (MRD1) is an effective measure that correlates with superior visual field except when the pupil is anatomically abnormal (oval, distracted (up or downward).
Response 5:
A comment addressing this concern has been added.

Comment 6:
Accepted average iris diameter of 11mm may over/underestimate.
Response 6:
The initial policy draft addressed this. However, the suggested alternative method of taping a millimeter rule to the brow or elsewhere in the photo [in the approximate plane of the cornea] has been incorporated.

Comment 7:
Lower eyelid blepharoplasty is rarely, if ever, a functional issue.
Response 7:
It is agreed that a functional lower eyelid blepharoplasty would be rare enough to make this non-covered as a matter of policy. Exceptions can be considered on appeal.