Medical necessity is not solely based on the opacity of the lens(es) when it comes to cataract surgery. For lens extraction to be considered medically necessary (and covered by Medicare), one or more of the following conditions must exist:

1. Cataract causes symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or non-operative means resulting in specific activity limitations and/or participation restrictions including, but not limited to:
   • Reading, watching television, driving, or meeting vocational or recreational needs.
2. Presence of concurrent intraocular disease (e.g. diabetic retinopathy) that requires monitoring or treatment, which is hindered by the cataract.
3. Lens-induced conditions that threaten vision or ocular health, including but not limited to phacomorphic or phacolytic glaucoma.
4. High likelihood of accelerated cataract formation due to an existing or planned ocular procedure (e.g., pars plana vitrectomy, iridocyclectomy, or trauma-related surgery) or treatments such as external beam radiation.
5. Cataract significantly impairing visualization or interfering with the performance of vitreoretinal surgery.
6. Intolerable anisometropia or aniseikonia resulting from lens extraction in the first eye, which cannot be corrected with glasses or contact lenses, despite satisfactory monocular visual acuity.

Noridian may, at its discretion, approve cataract surgery for conditions not specifically listed above. Coverage determinations will be based on documentation demonstrating medical necessity and alignment with accepted standards of care.

Review Noridian's Local Coverage Determination (LCD) for Cataract Surgery in Adults (L34203) and the Billing and Coding Article (A57195) for documentation requirements to support medical necessity.