Publication Number

100-3

Manual Section Number

10.1

Version Number

1

Effective Date of this Version

8/31/1992

Benefit Category

Diagnostic Tests (other)
Physicians' Services

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Indications and Limitations of Coverage

A - Pre-Surgery Evaluations

Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests 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.

Accordingly, where the only diagnosis is cataract(s), 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.

B - General Anesthesia

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.

Transmittal Number

61

Revision History

03/1986 - Eliminated prior references to routine coverage of assistant surgeon's services.  All claims for services of surgeons assisting at cataract surgery are subject to carrier medical review. Effective date NA. (TN 5)

09/1988 - Provided that Medicare payment not routinely made for pre-cataract surgery exams other than comprehensive eye exam and A-scan or B-scan.  Other tests only paid if diagnosis in addition to cataract is present and medical need for other tests fully documented. 09/14/1988. (TN 31)

08/1992 - Renamed title to indicate more clearly its subject matter. Effective date 08/31/1992. (TN 61) 

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