Q1004 — New technology intraocular lens category 4 as defined in federal register notice
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation of refractive testing demonstrating anisometropia ≥2 diopters and documentation that vision cannot be corrected with glasses or contact lenses.
- Operative/clinical documentation showing anatomical change, inflammatory response, or mechanical failure demonstrating the previously implanted monofocal IOL is ineffective or nonfunctional.
- Documentation that the patient meets all required clinical criteria for monocular IMT implantation (as specified elsewhere in the policy).
- Proof of patient age (≥65).
Key Coverage Criteria
- Meeting vocational or recreational needs;or
- Other daily activities;and
- Cataract removal surgery in adults is consideredmedically necessaryforanyof the following:
- The lens displays signs of cataract formation and the following criteria are met:The cataract is causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses;andVision loss interferes with one or more of the following:Reading;orViewing television;orDriving;orMeeting vocational or recreational needs;orOther daily activities;andOther eye disease(s) have been ruled out as the primary cause of decreased visual function including, but not limi [...]
- The cataract is causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses;and
- Vision loss interferes with one or more of the following:Reading;orViewing television;orDriving;orMeeting vocational or recreational needs;orOther daily activities;and
7 Active Policies
ANTHEM-CG-SURG-40 — CG-SURG-40 Cataract Removal Surgery for Adults
ANTHEM-CG-SURG-77 — CG-SURG-77 Refractive Surgery
BCBSIL-SUR713.025 — Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT)
BCBSMT-SUR713.025 — Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT)
BCBSNM-SUR713.025 — Intraocular Lens (IOLs) and Implantable Miniature Telescope (IMT)
Related Codes
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