Anthem Blue Cross Connecticut CG-SURG-40 Cataract Removal Surgery for Adults Form

This document addresses cataract extraction in adults as a treatment for visually-significant cataracts, when lens removal is needed to allow better visualization of the retina or as a component of another surgical procedure. This document does not address congenital cataracts.

Note: Please see the following related topics for additional information:

• CG-SURG-77 Refractive Surgery
• SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
• CG-SURG-114 Ophthalmic use of Nd:YAG Laser for Posterior Capsulotomy

Clinical Indications

Medically Necessary:

Cataract removal surgery in adults is considered medically necessary for any of the following:

1. The lens displays signs of cataract formation and the following criteria are met:
   1. The cataract is causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses;
      and
   2. Vision loss interferes with one or more of the following:
      1. Reading; or
      2. Viewing television; or
      3. Driving, or
      4. Meeting vocational or recreational needs; or
      5. Other daily activities;
         and
   3. Other eye disease(s) have been ruled out as the primary cause of decreased visual function including, but not limited to:
      1. Macular degeneration; or
      2. Diabetic retinopathy;
         and
   4. Surgery is reasonably expected to result in improved visual function.
      or
2. The individual has an underlying lens-related or other ophthalmologic disease for which cataract removal is indicated, including but not limited to the following:
   1. Phacomorphic glaucoma; or
   2. Phacolytic glaucoma; or
   3. Phacoanaphylactic endophthalmitis; or
   4. Dislocated or subluxated lens; or
   5. Angle closure glaucoma; or
   6. Elevated IOP associated with diagnosis of plateau iris configuration; or
   7. Uncontrolled pseudoexfoliation glaucoma;
      ​​​​​​​or
3. Lens removal is needed for either of the following:
   1. To allow better visualization of the retina; or
   2. As a component of another surgical procedure, including, but not limited to the following:
      1. Diabetes with diabetic retinopathy requiring photocoagulation management through clear media; or
      2. To monitor progression of glaucoma where opaque media limits visualization of the optic nerve or visual field assessment; or
      3. Preparation for vitrectomy; or
      4. Preparation for surgical repair of retinal detachment.

Not Medically Necessary:

Cataract removal surgery in adults is considered not medically necessary when the criteria specified above are not met, or when either of the following apply:

1. Glasses or visual aids provide satisfactory functional vision; or
2. When the visual function is not compromised by the cataract.