Aetna Cataract Surgery coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Pre-operative diagnostic testing is medically necessary: comprehensive eye examination OR brief/intermediate examination; AND A-scan ultrasound to determine appropriate pseudophakic IOL power.
• B-scan ultrasound is medically necessary in place of A-scan where direct visualization of the retina is difficult or impossible, including (ONE of): lid problems (severe edema, partial/total tarsorrhaphy), keratoprosthesis, corneal opacities (scars, severe edema), hyphema, hypopyon, miosis, dense cataract, pupillary membranes, or vitreous opacities (hemorrhage, inflammatory debris).
• B-scan ultrasound is medically necessary for the pre-operative work-up of individuals with Morgagnian cataract.
• Other pre-operative ophthalmologic tests may be medically necessary if there is another diagnosis in addition to cataracts.
• Specialized ophthalmologic services for routine pre-operative work-up that are medically necessary: optical coherence biometry; ultrasound A-scan diagnostic; ultrasound A-scan ophthalmic biometry; ultrasound with intraocular lens (IOL) power calculation.
• Cataract removal surgery is medically necessary for members with visual disability and best correctable Snellen acuity of 20/50 or worse when ALL of the following are met (subjective, objective, and educational): SUBJECTIVE - member perceives ability to carry out needed or desired activities is impaired, based on the member's own assessment of visual disability (impact on driving, viewing television, special occupational or avocational needs, particularly near-sight disability such as reading) and perception of impact on lifestyle (loss of independence, loss of income).
• Cataract removal for 20/50-or-worse members (OBJECTIVE, meet ALL): best correctable Snellen visual acuity in the affected eye is 20/50 or worse; AND eye examination confirms the cataract is the limiting factor for improving visual function when other factors do not preclude improvement following surgery; AND the member's medical and mental health permits surgery to be performed safely.
• Cataract removal for 20/50-or-worse members (EDUCATIONAL): member has been educated about the risks and benefits of cataract surgery, including alternatives to treatment, and determines that the expected reduction in disability outweighs the potential risk, cost, and inconvenience of surgery.
• Cataract removal surgery is medically necessary for members with visual disability and best correctable Snellen acuity of 20/40 or better when ALL of the following are met (subjective, objective, and educational): SUBJECTIVE - member perceives ability to carry out needed or desired activities is impaired, based on own assessment of visual disability (driving, television, occupational/avocational needs, near vision such as reading) and perception of impact on lifestyle (loss of independence, loss of income); AND complaints of glare disabling eyesight in daylight conditions inconsistent with visual acuity measured in a darkened room, but confirmed by documented assessment of visual functions under conditions of bright ambient light.
• Cataract removal for 20/40-or-better members (OBJECTIVE, meet ALL): best correctable Snellen visual acuity is 20/40 or better in the affected eye; AND there is significant loss of visual acuity in bright ambient light confirmed by procedures such as glare testing, brightness acuity testing (BAT), or contrast sensitivity testing, OR complaints of monocular diplopia or polyopia, OR visual disparity between the two eyes (anisometropia); AND eye examination confirms the cataract is the limiting factor for improving visual function when other factors do not preclude improvement following surgery; AND the member's medical and mental health permits surgery to be performed safely.
• Cataract removal for 20/40-or-better members (EDUCATIONAL): member has been educated about the risks and benefits of cataract surgery, including alternatives to treatment, and determines that the expected reduction in disability outweighs the potential risk, cost, and inconvenience of surgery.
• Cataract removal surgery is medically necessary for one-eyed members with visual disability of 20/50 or worse due to cataract (member with irreversible, untreatable legal blindness of 20/200 or worse in the other eye).
• Cataract removal surgery (removal of the lens) is medically necessary WITHOUT REGARD to visual disability when ANY of the following is met: member has lens-induced disease (phacomorphic glaucoma, phacolytic glaucoma, phacoanaphylactic endophthalmitis, dislocated or subluxated lens); OR there is need to visualize the fundus (retina) in an eye with potential for sight in any of: diabetes with significant risk of reduced visual acuity (diabetic retinopathy) requiring photocoagulation management through clear media or to monitor glaucoma, to prepare for vitrectomy, or to prepare for surgical repair of retinal detachment; OR when other special investigations demonstrate intra-ocular pathology where further attention is important and requires clear media.
• Capsular tension rings (e.g., StabilEyes) are medically necessary for stabilization of the lens capsule during IOL placement in conditions associated with weak or partially absent zonules, including (ONE of): primary zonular weakness (e.g., Marfan syndrome), secondary zonular weakness (e.g., trauma or vitrectomy), zonulysis, pseudo-exfoliation, Marchesani's syndrome, or unexpected loss of zonules during surgery. (Use of capsular tension rings is integral to ocular surgery and is not separately reimbursed.)
• Nd:YAG laser capsulotomy is medically necessary when performed 6 months or more following cataract extraction in members with visually significant clouding (opacification) of the posterior capsule. Requests for Nd:YAG laser capsulotomy performed within 6 months of cataract extraction should be forwarded for medical review.
• Combined glaucoma and cataract surgery is medically necessary for persons with a visually significant cataract who have uncontrolled glaucoma despite maximal medical therapy and/or laser trabeculoplasty.
• Secondary lens (IOL) implantation is medically necessary following complicated cataract surgery (e.g., dislocated IOL, retained cataract lens fragment removal).
• Intraocular lens (IOL) implantation is medically necessary for aphakia, including standard posterior chamber IOLs for hyperopia, standard anterior chamber IOLs, standard fixed monofocal posterior chamber IOLs, aspheric monofocal posterior chamber IOLs, and standard fixed monofocal posterior chamber ultraviolet-absorbing IOLs.
• Femtosecond laser-assisted cataract surgery is considered an equally effective alternative to standard methods of cataract removal and is medically necessary.
• For members who elect a non-covered new-technology IOL (multifocal, accommodating, or toric), the cataract removal and lens implantation are medically necessary if the criteria for cataract surgery are met (only the new-technology lens itself is non-covered).
• Inpatient setting for cataract removal surgery is generally not medically necessary; however, inpatient surgery is medically necessary for ANY of the following members: medical conditions present requiring prolonged post-operative observation by a nurse or skilled personnel, or member requires general medical and nursing care for a particularly complex ocular procedure; OR member has multiple ocular conditions (e.g., best correctable vision in the non-operated eye is 20/200 or worse); OR member will undergo multiple ocular procedures (e.g., extraordinary medical circumstances where it may be dangerous or life-threatening to undergo anesthesia twice, so dual cataract removal is performed); OR member is mentally debilitated, diagnosed as mentally ill, or functionally incapacitated such that risk of injury exists in the immediate post-operative period, or physical disability prevents satisfactory immediate post-operative care.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 66820·PA verdict·Rate
• 66821·PA verdict·Rate
• 66830·PA verdict·Rate
• 66982·PA verdict·Rate
• 66984·PA verdict·Rate
• 66987·PA verdict·Rate
• 66988·PA verdict·Rate
• 76511·PA verdict·Rate
• 76516·PA verdict·Rate
• 92136·PA verdict·Rate

Documentation required

• For members with visual disability and 20/50-or-worse acuity: documentation of the member's subjective perception that the ability to carry out needed/desired activities is impaired, including the member's own assessment of visual disability impact (driving, television, occupational/avocational needs, near-vision activities such as reading) and perception of impact on lifestyle (loss of independence, loss of income).
• For 20/50-or-worse members: documentation of best correctable Snellen visual acuity in the affected eye (20/50 or worse); eye examination documentation confirming the cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives with the member's determination that expected reduction in disability outweighs risk, cost, and inconvenience.
• For members with visual disability and 20/40-or-better acuity: documentation of subjective perception of visual disability and functional impairment (driving, television, occupational/avocational/near-vision impact; lifestyle impact such as loss of independence/income).
• For 20/40-or-better members: documentation of glare complaints in daylight conditions inconsistent with acuity measured in a darkened room, with a documented assessment of visual functions under bright ambient light; best correctable Snellen acuity (20/40 or better); documentation of significant loss of visual acuity in bright ambient light via glare testing/BAT/contrast sensitivity testing, OR documentation of monocular diplopia/polyopia, OR documentation of anisometropia; eye examination confirming cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives.
• For Morgagnian cataract: documentation supporting the need for B-scan ultrasound.
• For lens-induced disease: medical documentation of the specific condition.
• For zonular weakness conditions requiring a capsular tension ring: documentation of zonular status.
• Functional impairment assessment instruments such as the VF-14, the activities of daily vision scale, and the visual activities questionnaire are referenced as available for assessing functional impairment related to cataract (referenced, not explicitly mandated).

Frequently asked questions

When does Aetna cover Cataract Surgery (CPT 66820), and what gets it denied?

Aetna covers medically necessary cataract removal with implantation of a standard monofocal intraocular lens when the cataract is the limiting factor on vision and the member meets defined visual-disability gates: best-corrected acuity of 20/50 or worse with documented functional impairment, OR 20/40 or better only with confirmed disabling glare, monocular diplopia/polyopia, or anisometropia; surgery is also covered without regard to acuity for lens-induced disease or when the fundus must be visualized. Premium IOLs (multifocal, accommodating, toric, extended-vision, trifocal, light-adjustable), piggyback IOLs, capsular-bag prostheses, prophylactic/concurrent/routine Nd:YAG capsulotomy, and most routine pre-op specialty testing are not covered. The bulletin is silent on whether routine prior authorization is required, though within-6-month Nd:YAG capsulotomy requests are forwarded for medical review. Coverage criteria include: Pre-operative diagnostic testing is medically necessary: comprehensive eye examination OR brief/intermediate examination; AND A-scan ultrasound to determine appropriate pseudophakic IOL power.; B-scan ultrasound is medically necessary in place of A-scan where direct visualization of the retina is difficult or impossible, including (ONE of): lid problems (severe edema, partial/total tarsorrhaphy), keratoprosthesis, corneal opacities (scars, severe edema), hyphema, hypopyon, miosis, dense cataract, pupillary membranes, or vitreous opacities (hemorrhage, inflammatory debris).; B-scan ultrasound is medically necessary for the pre-operative work-up of individuals with Morgagnian cataract.; Other pre-operative ophthalmologic tests may be medically necessary if there is another diagnosis in addition to cataracts.; Specialized ophthalmologic services for routine pre-operative work-up that are medically necessary: optical coherence biometry; ultrasound A-scan diagnostic; ultrasound A-scan ophthalmic biometry; ultrasound with intraocular lens (IOL) power calculation.; Cataract removal surgery is medically necessary for members with visual disability and best correctable Snellen acuity of 20/50 or worse when ALL of the following are met (subjective, objective, and educational): SUBJECTIVE - member perceives ability to carry out needed or desired activities is impaired, based on the member's own assessment of visual disability (impact on driving, viewing television, special occupational or avocational needs, particularly near-sight disability such as reading) and perception of impact on lifestyle (loss of independence, loss of income).; Cataract removal for 20/50-or-worse members (OBJECTIVE, meet ALL): best correctable Snellen visual acuity in the affected eye is 20/50 or worse; AND eye examination confirms the cataract is the limiting factor for improving visual function when other factors do not preclude improvement following surgery; AND the member's medical and mental health permits surgery to be performed safely.; Cataract removal for 20/50-or-worse members (EDUCATIONAL): member has been educated about the risks and benefits of cataract surgery, including alternatives to treatment, and determines that the expected reduction in disability outweighs the potential risk, cost, and inconvenience of surgery.; Cataract removal surgery is medically necessary for members with visual disability and best correctable Snellen acuity of 20/40 or better when ALL of the following are met (subjective, objective, and educational): SUBJECTIVE - member perceives ability to carry out needed or desired activities is impaired, based on own assessment of visual disability (driving, television, occupational/avocational needs, near vision such as reading) and perception of impact on lifestyle (loss of independence, loss of income); AND complaints of glare disabling eyesight in daylight conditions inconsistent with visual acuity measured in a darkened room, but confirmed by documented assessment of visual functions under conditions of bright ambient light.; Cataract removal for 20/40-or-better members (OBJECTIVE, meet ALL): best correctable Snellen visual acuity is 20/40 or better in the affected eye; AND there is significant loss of visual acuity in bright ambient light confirmed by procedures such as glare testing, brightness acuity testing (BAT), or contrast sensitivity testing, OR complaints of monocular diplopia or polyopia, OR visual disparity between the two eyes (anisometropia); AND eye examination confirms the cataract is the limiting factor for improving visual function when other factors do not preclude improvement following surgery; AND the member's medical and mental health permits surgery to be performed safely.; Cataract removal for 20/40-or-better members (EDUCATIONAL): member has been educated about the risks and benefits of cataract surgery, including alternatives to treatment, and determines that the expected reduction in disability outweighs the potential risk, cost, and inconvenience of surgery.; Cataract removal surgery is medically necessary for one-eyed members with visual disability of 20/50 or worse due to cataract (member with irreversible, untreatable legal blindness of 20/200 or worse in the other eye).; Cataract removal surgery (removal of the lens) is medically necessary WITHOUT REGARD to visual disability when ANY of the following is met: member has lens-induced disease (phacomorphic glaucoma, phacolytic glaucoma, phacoanaphylactic endophthalmitis, dislocated or subluxated lens); OR there is need to visualize the fundus (retina) in an eye with potential for sight in any of: diabetes with significant risk of reduced visual acuity (diabetic retinopathy) requiring photocoagulation management through clear media or to monitor glaucoma, to prepare for vitrectomy, or to prepare for surgical repair of retinal detachment; OR when other special investigations demonstrate intra-ocular pathology where further attention is important and requires clear media.; Capsular tension rings (e.g., StabilEyes) are medically necessary for stabilization of the lens capsule during IOL placement in conditions associated with weak or partially absent zonules, including (ONE of): primary zonular weakness (e.g., Marfan syndrome), secondary zonular weakness (e.g., trauma or vitrectomy), zonulysis, pseudo-exfoliation, Marchesani's syndrome, or unexpected loss of zonules during surgery. (Use of capsular tension rings is integral to ocular surgery and is not separately reimbursed.); Nd:YAG laser capsulotomy is medically necessary when performed 6 months or more following cataract extraction in members with visually significant clouding (opacification) of the posterior capsule. Requests for Nd:YAG laser capsulotomy performed within 6 months of cataract extraction should be forwarded for medical review.; Combined glaucoma and cataract surgery is medically necessary for persons with a visually significant cataract who have uncontrolled glaucoma despite maximal medical therapy and/or laser trabeculoplasty.; Secondary lens (IOL) implantation is medically necessary following complicated cataract surgery (e.g., dislocated IOL, retained cataract lens fragment removal).; Intraocular lens (IOL) implantation is medically necessary for aphakia, including standard posterior chamber IOLs for hyperopia, standard anterior chamber IOLs, standard fixed monofocal posterior chamber IOLs, aspheric monofocal posterior chamber IOLs, and standard fixed monofocal posterior chamber ultraviolet-absorbing IOLs.; Femtosecond laser-assisted cataract surgery is considered an equally effective alternative to standard methods of cataract removal and is medically necessary.; For members who elect a non-covered new-technology IOL (multifocal, accommodating, or toric), the cataract removal and lens implantation are medically necessary if the criteria for cataract surgery are met (only the new-technology lens itself is non-covered).; Inpatient setting for cataract removal surgery is generally not medically necessary; however, inpatient surgery is medically necessary for ANY of the following members: medical conditions present requiring prolonged post-operative observation by a nurse or skilled personnel, or member requires general medical and nursing care for a particularly complex ocular procedure; OR member has multiple ocular conditions (e.g., best correctable vision in the non-operated eye is 20/200 or worse); OR member will undergo multiple ocular procedures (e.g., extraordinary medical circumstances where it may be dangerous or life-threatening to undergo anesthesia twice, so dual cataract removal is performed); OR member is mentally debilitated, diagnosed as mentally ill, or functionally incapacitated such that risk of injury exists in the immediate post-operative period, or physical disability prevents satisfactory immediate post-operative care.. Applies to 10 codes: 66820, 66821, 66830, 66982, 66984, 66987, 66988, 76511, 76516, 92136. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin describes no general precertification submission process. It states only that requests for Nd:YAG laser capsulotomy performed within 6 months of cataract extraction should be forwarded for medical review, without detailing the mechanism for that review. Documentation: For members with visual disability and 20/50-or-worse acuity: documentation of the member's subjective perception that the ability to carry out needed/desired activities is impaired, including the member's own assessment of visual disability impact (driving, television, occupational/avocational needs, near-vision activities such as reading) and perception of impact on lifestyle (loss of independence, loss of income).; For 20/50-or-worse members: documentation of best correctable Snellen visual acuity in the affected eye (20/50 or worse); eye examination documentation confirming the cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives with the member's determination that expected reduction in disability outweighs risk, cost, and inconvenience.; For members with visual disability and 20/40-or-better acuity: documentation of subjective perception of visual disability and functional impairment (driving, television, occupational/avocational/near-vision impact; lifestyle impact such as loss of independence/income).; For 20/40-or-better members: documentation of glare complaints in daylight conditions inconsistent with acuity measured in a darkened room, with a documented assessment of visual functions under bright ambient light; best correctable Snellen acuity (20/40 or better); documentation of significant loss of visual acuity in bright ambient light via glare testing/BAT/contrast sensitivity testing, OR documentation of monocular diplopia/polyopia, OR documentation of anisometropia; eye examination confirming cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives.; For Morgagnian cataract: documentation supporting the need for B-scan ultrasound.; For lens-induced disease: medical documentation of the specific condition.; For zonular weakness conditions requiring a capsular tension ring: documentation of zonular status.; Functional impairment assessment instruments such as the VF-14, the activities of daily vision scale, and the visual activities questionnaire are referenced as available for assessing functional impairment related to cataract (referenced, not explicitly mandated). Policy exclusions and limitations: Piggyback posterior chamber IOLs (placement of 2 IOLs in the same eye) are considered experimental, investigational, or unproven.; Capsular bag prosthesis containing an intraocular lens (e.g., LensOne) is considered experimental, investigational, or unproven.; Nd:YAG laser capsulotomy is experimental/investigational/unproven (and not covered) in any of the following: if performed concurrently with cataract surgery; if performed prophylactically; or if scheduled routinely after cataract surgery without regard to whether there is clinically significant opacification of the posterior capsule.; The following specialized ophthalmologic services are experimental/investigational/unproven for routine pre-operative evaluation of cataracts (of no proven value unless another indication beyond cataracts exists): artificial intelligence (AI)-based algorithms for analyzing cataract surgery videos.; Corneal pachymetry is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0681).; Corneal topography is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0130).; Electrophysiologic tests (including electroretinography) are experimental/investigational/unproven for routine pre-operative cataract evaluation.; External photography is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0734).; Fluorescein angiography is experimental/investigational/unproven for routine pre-operative cataract evaluation.; Formal visual fields are experimental/investigational/unproven for routine pre-operative cataract evaluation.; Specialized color vision tests are experimental/investigational/unproven for routine pre-operative cataract evaluation.; Specular photographic microscopy is experimental/investigational/unproven for routine pre-operative cataract evaluation.; Ultrasound, contact B-scan, diagnostic is experimental/investigational/unproven for routine pre-operative cataract evaluation (except where B-scan medically necessary criteria are met).; Ultrasound, immersion B-scan, diagnostic is experimental/investigational/unproven for routine pre-operative cataract evaluation (except where B-scan medically necessary criteria are met).; Visual evoked potentials are experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0181).; Accommodating posterior chamber IOLs (e.g., Crystalens) are not medically necessary (premium/deluxe IOL intended to obviate the need for reading glasses).; Multi-focal posterior chamber IOLs are not medically necessary (premium IOLs intended to obviate the need for reading glasses), including Array Model SA40, ReZoom, Tecnis ZM900, Tecnis Model ZKB00/ZMAOO, AcrySof IQ Vivity Extended Vision IOL (DFT015), AcrySof ReSTOR, Acrysof ReSTOR SA60D3, Acrysof Natural ReSTOR SN60D3, AcrySof ReSTOR Aspheric SN6AD1, and AcrySof ReSTOR Aspheric SN6AD3.; Astigmatism-correcting (toric) posterior chamber IOLs are not medically necessary, including Staar Toric IOL, Staar Elastic Toric Lens AA4203TL, Tecnis Toric ZCT150, AcrySof IQ Vivity Toric Extended Vision IOLs, AcrySof Toric IOL, AcrySof Aspheric Toric IOL series, AcrySof Toric SA60T series, AcrySof Toric SA60T, and Acrysof IQ Toric series.; Extended-vision and other premium IOLs are not medically necessary, including the Clareon Vivity Extended Vision IOL, FineVision POD FT IOL, Lenstec SBL-3 multifocal IOL, light-adjustable IOLs, multifocal astigmatism-correcting (toric) IOLs (ReSTOR Multifocal Toric IOL), accommodating toric IOLs (Trulign Toric IOL), extended depth-of-focus multifocal lens (Tecnis Symfony ZXR00), and trifocal IOLs (e.g., Alcon PanOptix).; Optiwave Refractive Analysis (ORA) is not medically necessary for cataract surgery.; DuoVisc (ophthalmic viscosurgical device) is considered incidental to cataract surgery and is not separately reimbursed.; Cataract removal surgery is not medically necessary when glasses or visual aids provide satisfactory functional vision.; Cataract removal surgery is not medically necessary when the member's lifestyle is not compromised.; Cataract removal surgery is not medically necessary when the member is medically unfit (e.g., comatose patients, organic brain syndrome, end-stage Alzheimer's disease, persons with no light perception) in whom cataract surgery will not improve the member's independence.; Contrast sensitivity testing, glare testing (BAT), and potential vision testing (PAM) are considered integral to the ophthalmologic examination and are not separately reimbursed. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Cataract Surgery?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin describes no general precertification submission process. It states only that requests for Nd:YAG laser capsulotomy performed within 6 months of cataract extraction should be forwarded for medical review, without detailing the mechanism for that review. Documentation: For members with visual disability and 20/50-or-worse acuity: documentation of the member's subjective perception that the ability to carry out needed/desired activities is impaired, including the member's own assessment of visual disability impact (driving, television, occupational/avocational needs, near-vision activities such as reading) and perception of impact on lifestyle (loss of independence, loss of income).; For 20/50-or-worse members: documentation of best correctable Snellen visual acuity in the affected eye (20/50 or worse); eye examination documentation confirming the cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives with the member's determination that expected reduction in disability outweighs risk, cost, and inconvenience.; For members with visual disability and 20/40-or-better acuity: documentation of subjective perception of visual disability and functional impairment (driving, television, occupational/avocational/near-vision impact; lifestyle impact such as loss of independence/income).; For 20/40-or-better members: documentation of glare complaints in daylight conditions inconsistent with acuity measured in a darkened room, with a documented assessment of visual functions under bright ambient light; best correctable Snellen acuity (20/40 or better); documentation of significant loss of visual acuity in bright ambient light via glare testing/BAT/contrast sensitivity testing, OR documentation of monocular diplopia/polyopia, OR documentation of anisometropia; eye examination confirming cataract is the limiting factor; documentation that medical and mental health permit surgery; and documentation of patient education about risks, benefits, and alternatives.; For Morgagnian cataract: documentation supporting the need for B-scan ultrasound.; For lens-induced disease: medical documentation of the specific condition.; For zonular weakness conditions requiring a capsular tension ring: documentation of zonular status.; Functional impairment assessment instruments such as the VF-14, the activities of daily vision scale, and the visual activities questionnaire are referenced as available for assessing functional impairment related to cataract (referenced, not explicitly mandated).

What does Aetna exclude for Cataract Surgery?

Policy exclusions and limitations: Piggyback posterior chamber IOLs (placement of 2 IOLs in the same eye) are considered experimental, investigational, or unproven.; Capsular bag prosthesis containing an intraocular lens (e.g., LensOne) is considered experimental, investigational, or unproven.; Nd:YAG laser capsulotomy is experimental/investigational/unproven (and not covered) in any of the following: if performed concurrently with cataract surgery; if performed prophylactically; or if scheduled routinely after cataract surgery without regard to whether there is clinically significant opacification of the posterior capsule.; The following specialized ophthalmologic services are experimental/investigational/unproven for routine pre-operative evaluation of cataracts (of no proven value unless another indication beyond cataracts exists): artificial intelligence (AI)-based algorithms for analyzing cataract surgery videos.; Corneal pachymetry is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0681).; Corneal topography is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0130).; Electrophysiologic tests (including electroretinography) are experimental/investigational/unproven for routine pre-operative cataract evaluation.; External photography is experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0734).; Fluorescein angiography is experimental/investigational/unproven for routine pre-operative cataract evaluation.; Formal visual fields are experimental/investigational/unproven for routine pre-operative cataract evaluation.; Specialized color vision tests are experimental/investigational/unproven for routine pre-operative cataract evaluation.; Specular photographic microscopy is experimental/investigational/unproven for routine pre-operative cataract evaluation.; Ultrasound, contact B-scan, diagnostic is experimental/investigational/unproven for routine pre-operative cataract evaluation (except where B-scan medically necessary criteria are met).; Ultrasound, immersion B-scan, diagnostic is experimental/investigational/unproven for routine pre-operative cataract evaluation (except where B-scan medically necessary criteria are met).; Visual evoked potentials are experimental/investigational/unproven for routine pre-operative cataract evaluation (except per CPB 0181).; Accommodating posterior chamber IOLs (e.g., Crystalens) are not medically necessary (premium/deluxe IOL intended to obviate the need for reading glasses).; Multi-focal posterior chamber IOLs are not medically necessary (premium IOLs intended to obviate the need for reading glasses), including Array Model SA40, ReZoom, Tecnis ZM900, Tecnis Model ZKB00/ZMAOO, AcrySof IQ Vivity Extended Vision IOL (DFT015), AcrySof ReSTOR, Acrysof ReSTOR SA60D3, Acrysof Natural ReSTOR SN60D3, AcrySof ReSTOR Aspheric SN6AD1, and AcrySof ReSTOR Aspheric SN6AD3.; Astigmatism-correcting (toric) posterior chamber IOLs are not medically necessary, including Staar Toric IOL, Staar Elastic Toric Lens AA4203TL, Tecnis Toric ZCT150, AcrySof IQ Vivity Toric Extended Vision IOLs, AcrySof Toric IOL, AcrySof Aspheric Toric IOL series, AcrySof Toric SA60T series, AcrySof Toric SA60T, and Acrysof IQ Toric series.; Extended-vision and other premium IOLs are not medically necessary, including the Clareon Vivity Extended Vision IOL, FineVision POD FT IOL, Lenstec SBL-3 multifocal IOL, light-adjustable IOLs, multifocal astigmatism-correcting (toric) IOLs (ReSTOR Multifocal Toric IOL), accommodating toric IOLs (Trulign Toric IOL), extended depth-of-focus multifocal lens (Tecnis Symfony ZXR00), and trifocal IOLs (e.g., Alcon PanOptix).; Optiwave Refractive Analysis (ORA) is not medically necessary for cataract surgery.; DuoVisc (ophthalmic viscosurgical device) is considered incidental to cataract surgery and is not separately reimbursed.; Cataract removal surgery is not medically necessary when glasses or visual aids provide satisfactory functional vision.; Cataract removal surgery is not medically necessary when the member's lifestyle is not compromised.; Cataract removal surgery is not medically necessary when the member is medically unfit (e.g., comatose patients, organic brain syndrome, end-stage Alzheimer's disease, persons with no light perception) in whom cataract surgery will not improve the member's independence.; Contrast sensitivity testing, glare testing (BAT), and potential vision testing (PAM) are considered integral to the ophthalmologic examination and are not separately reimbursed. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT