Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-114 Ophthalmic use of Nd:YAG Laser for Posterior Capsulotomy Form


YAG laser posterior capsulotomy

Indications

(457101) Is the opacification causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses? 
(457102) Does vision loss interfere with daily activities such as reading, viewing television, driving, meeting vocational or recreational needs? 
(457103) Have other eye diseases been ruled out as the primary cause of decreased visual function including, but not limited to macular degeneration or diabetic retinopathy? 
(457104) Is surgery expected to result in improved visual function? 
(457105) Is capsulotomy needed to allow better visualization of the posterior segment or as a component of another surgical procedure, such as management through clear media for diabetes with diabetic retinopathy requiring photocoagulation? 

YesNoN/A
YesNoN/A
YesNoN/A

Sign up to see the rest of the questions

Unlock the remaining questions and the full coverage workflow.

Sign up for free
Effective Date

01/03/2024

Last Reviewed

11/09/2023

Original Document

  Reference



This document addresses YAG laser posterior capsulotomy for the treatment of posterior capsule opacification.

Note: This document does not address YAG laser anterior capsulotomy.

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

  • CG-SURG-40 Cataract Removal Surgery for Adults

Clinical Indications

Medically Necessary:

YAG laser posterior capsulotomy is considered medically necessary for any of the following:

  1. For individuals with posterior capsular opacification when all of the following criteria are met:
    1. The opacification 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: reading, viewing television, driving, meeting vocational or recreational needs, or 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 macular degeneration or diabetic retinopathy; and
    4. Surgery is expected to result in improved visual function;
      or
  2. For individuals with posterior capsular opacification when capsulotomy is needed to allow better visualization of the posterior segment or 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 surgical repair of retinal detachment;
      or
  3. Capsular block syndrome, also known as capsular bag distension syndrome, viscoelastic entrapment syndrome, capsular bag hyperdistension, distended capsular bag in early postoperative period, and capsulorhexis block syndrome.

Not Medically Necessary:

YAG laser posterior capsulotomy is considered not medically necessary when the criteria specified above are not met.