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

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.