00136
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Agree to participate in postoperative visual training with a low vision specialist;and
- An intraocular telescope (for example, the Implantable Miniature Telescope) is consideredmedically necessaryfor monocular implantation to improve vision in individuals 65 years of age or older when all of the following criteria are met:
- Achieve at least a 5-letter improvement on the Early Treatment Diabetic Retinopathy Study chart with an external telescope in the eye scheduled for surgery;and
- Agree to undergo pre-surgery training and assessment (typically 2 to 4 sessions) with low vision specialists (optometrist or occupational therapist) in the use of an external telescope sufficient for assessment and for the individual to make an informed decision;and
- Have adequate peripheral vision in the eye not scheduled for surgery;and
- Have retinal findings of geographic atrophy or disciform scar with foveal involvement, as determined by fluorescein angiography;and
1 Active Policy
ANTHEM-CG-SURG-96 — CG-SURG-96 Intraocular Telescope
Related Codes
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