Summary Of Evidence

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Analysis of Evidence

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Abstract:

Corneal Pachymetry is the measurement of corneal thickness and commonly uses either ultrasonic or optical methods. Measurement of corneal thickness in individuals presenting with increased intraocular pressure assists in determining if there is a risk of glaucoma or if the individual's increased eye pressure is the result of abnormal corneal thickness. The test must be integral to the medical management decision-making of the patient. Coverage is limited to ophthalmologists and optometrists.

Indications and Limitations:

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed to determine the amount of endothelial trauma sustained during surgery, assessment of the health of the cornea pre-operatively in Fuch's dystrophy, post ocular trauma and for the assessment of corneal thickness or (in suspected glaucoma) following the diagnosis of increased intraocular pressure prior to the initiation of a treatment regimen for glaucoma. It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma or surgery.

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed only by ophthalmologist and optometrists.

Medicare will not pay for use of pachymetry when used in preparation for surgery to reshape the cornea of the eye for the purpose of correcting visual problems (refractive surgery), such as myopia (nearsightedness) and hyperopia (farsightedness).

Whether patients have been previously diagnosed and are under treatment for glaucoma or are newly diagnosed, pachymetry will be covered once per lifetime, or more frequently in cases where there has been surgical or non-surgical trauma.

When there is a question of corneal disease supported by diagnosis, then pachymetry may be performed at the same time as endothelial cell count.

Other Comments:
For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.