Cataract Removal Surgery Targeted Probe and Educate Review Results

The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 66984 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. The quarterly edit effectiveness results from October 1, 2022 through December 31, 2022 are as follows:

Top Denial Reasons

  • Documentation Requirements for Cataract Surgery
  • Medical Necessity for Cataract Surgery

Educational Resources


Documentation Requirements for Cataract Surgery

Per Local Coverage Determination (LCD) L34203 (JE) required documentation to support medical necessity must include:

  • Statement indicating specific symptomatic visual functional impairment resulting in inability to perform activates of daily living satisfactorily. Activities of daily living include but are not limited to, reading, watching television, and driving.
  • Best corrected visual acuity test at distance showing inability to correct the patient’s visual function with changes to glasses or contact lenses.
  • Degree of lens opacity correlating impairment of best corrected visual acuity with cataract as primary cause of visual compromise.
  • Attestation indicating patient’s visual function impairment is believed not to be correctable by any other means.
  • Attestation indicating cataract is believed to be significantly contributing to impairment when other ocular diseases are present.
  • Statement that the patient wishes to have surgical correction and that risks, benefits and alternatives were explained.
  • Appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic examination.
  • Any specialized ophthalmologic studies are completed for medically necessary reasons unique to that patient.

For additional information, reference Cataract Surgery in Adults LCD L34203 (JE).

Medical Necessity for Cataract Surgery

Per Local Coverage Determination (LCD) L34203 (JE) cataract surgery is not considered medically necessary based on lens opacity only when there are no associated symptoms. Cataract surgery would be considered medically necessary if:

  • There is symptomatic visual function impairment that cannot be corrected with glasses or contact lenses and is prohibiting the patient from performing activities of daily living.
  • The cataract is inhibiting monitoring or treatment of related intraocular disease such as diabetic retinopathy.
  • There is disease of the lens that threatens the patient’s vision or visual health.
  • The cataract development has a high potential of accelerating due to a related or subsequent procedure and external beam radiation.
  • Vitreoretinal surgery is planned, and the cataract is interfering with proceeding with the planned surgery.
  • The patient developed anisometropia or aniseikonia after lens extraction in the first eye that is not tolerable and uncorrectable with glassed or contact lenses.

For additional information, reference Cataract Surgery in Adults LCD L34203 (JE).


Last Updated Wed, 18 Jan 2023 13:49:14 +0000