Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that cataract is defined as an opacity or loss of optical clarity of the crystalline lens. Cataract 
development follows a continuum extending from minimal changes in the crystalline lens to the extreme stage 
of total opacity. Cataracts may be due to a variety of causes. Age-related cataract (senile cataract) is the most 
common type found in adults. Other types are pediatric (both congenital and acquired), traumatic, toxic and 
secondary (meaning the result of another disease process) cataract. 
 
Most cataracts are not visible to the naked eye until they become dense enough (mature or hypermature) to 
cause blindness. However, a cataract at any stage of development can be observed through a sufficiently dilated 
pupil using a slit lamp biomicroscope. In settings where this instrument is unavailable (e.g., skilled nursing 
facility), a direct ophthalmoscope can be used to assess the degree to which the fundus reflectivity (red reflex) 
is impaired by the ocular media. There is no scientifically proven medical treatment for cataracts. 
 
In general, cataract surgery is performed to alleviate visual impairments attributable to lens opacity. There are 
uncommon situations when lens extraction becomes medically necessary for anatomic rather than optical 
reasons. These include lens induced angle closure (e.g., microspherophakia) and lens subluxation (e.g., Marfan 
syndrome). In other situations, cataract extraction might be medically indicated with relatively less opacity 
because of intolerable optical imbalance. Most commonly, this would be due to surgically induced 
anisometropia (a significant difference in refractive errors between the eyes) or aniseikonia (a difference in 
magnification as a result of prior lens extraction in the one eye). Some patients may elect lens removal and 
replacement primarily for refractive benefits to reduce their dependence on spectacles. Such elective 
procedures are not medically necessary and are called refractive lens exchanges to distinguish them from 
medically indicated cataract surgery. Finally, advanced cataracts may need to be removed to properly visualize, 
treat, and monitor retinal disease, apart from the patients visual symptoms and potential. 
 
This policy statement defines the medical necessity for cataract and other lens extraction in adults, and 
specifies the required documentation of the preoperative evaluation necessary to justify the procedure. This 
A/B Medicare Administrative Contractor (MAC) encourages but does not require providers to use the 
framework of the International Classification of Functioning, Disability, and Health (ICF) to organize the 
information related to relevant structural/functional impairments, activity limitations and/or participation restrictions, and any environmental factors influencing the decision to recommend cataract surgery. 
 
Medical Necessity 
 
Medical necessity for cataract surgery is not based solely on the presence of opacity in the lens(es). Lens 
extraction is considered medically necessary and therefore covered by Medicare when 1 (or more) of the 
following conditions or circumstances exists: 
1. Cataract causing symptomatic (i.e., causing the patient to seek medical attention) 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, viewing television, driving, or meeting vocational or recreational needs. 
2. Concomitant intraocular disease (e.g., diabetic retinopathy, or intraocular tumor) requiring monitoring 
or treatment that is prevented by the presence of cataract. 
3. Lens-induced disease threatening vision or ocular health (including, but not limited to, phacomorphic or 
phacolytic glaucoma). 
4. High probability of accelerating cataract development as a result of a concomitant or subsequent 
procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments 
such as external beam irradiation. 
5. Cataract interfering with the performance of vitreoretinal surgery. 
6. Intolerable anisometropia or aniseikonia uncorrectable with glasses or contact lenses exists as a result of 
lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity). 
 
Medicare will consider coverage of cataract surgery for circumstances not listed above. Coverage will be based 
on documentation that supports medical necessity and is compatible with the accepted standards of medical 
care. Medicare coverage extends only to standard non-correcting prosthetic lenses. Advanced technology 
prosthetic lenses are not covered. 
 
Visual Acuity 
 
The Snellen chart is frequently used as a screening tool to measure visual acuity. However, testing using high 
contrast letters viewed in dark room conditions, can underestimate the functional impairments caused by some 
cataracts in common real-life situations (e.g., glare conditions, poor contrast environments, reading, halos and 
starbursts at night, and impaired optical quality causing monocular diplopia and ghosting). An evaluation of 
visual acuity alone can neither rule in nor rule out the need for surgery. Visual acuity should be recorded and 
considered in the context of the patients visual impairment and other ocular findings. 
 
Second Eye Surgery 
 
Surgery is generally not performed in both eyes during the same surgical session because of the potential for 
bilateral visual loss. The publication, Cataract in the Adult Eye, Preferred Practice Pattern

, by the American 
Academy of Ophthalmology

, describes circumstances under which bilateral cataract surgery might be an 
option (e.g., a significant cataract in the second eye). 
 
In the more common situation, where surgery is performed sequentially on separate days for bilateral visually 
symptomatic cataracts, the appropriate interval between the first-eye surgery and second-eye surgery is 
influenced by several factors: 1. The patient's visual needs; 
2. The patient's preferences; 
3. Visual function in the second eye; 
4. The medical and refractive stability of the first eye; 
5. The need to restore binocular vision and resolve anisometropia; 
6. An adequate interval of time has elapsed to evaluate and treat early postoperative complications in first 
eye, such as endophthalmitis; and/or 
7. Logistical and travel considerations of the patient. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L34413: Cataract Surgery. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.