Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 06101 | Wellpoint Federal | MAC - Part A | IL |
| 06201 | Wellpoint Federal | MAC - Part A | MN |
| 06301 | Wellpoint Federal | MAC - Part A | WI |
| 06102 | Wellpoint Federal | MAC - Part B | IL |
| 06202 | Wellpoint Federal | MAC - Part B | MN |
| 06302 | Wellpoint Federal | MAC - Part B | WI |
| 13101 | Wellpoint Federal | A and B and HHH MAC | CT |
| 13201 | Wellpoint Federal | A and B and HHH MAC | NY |
| 13102 | Wellpoint Federal | A and B and HHH MAC | CT |
| 13202 | Wellpoint Federal | A and B and HHH MAC | DN |
| 13282 | Wellpoint Federal | A and B and HHH MAC | UN |
| 13292 | Wellpoint Federal | A and B and HHH MAC | QN |
| 14411 | Wellpoint Federal | A and B and HHH MAC | RI |
| 14211 | Wellpoint Federal | A and B and HHH MAC | MA |
| 14311 | Wellpoint Federal | A and B and HHH MAC | NH |
| 14511 | Wellpoint Federal | A and B and HHH MAC | VT |
| 14111 | Wellpoint Federal | A and B and HHH MAC | ME |
| 14112 | Wellpoint Federal | A and B and HHH MAC | ME |
| 14212 | Wellpoint Federal | A and B and HHH MAC | MA |
| 14312 | Wellpoint Federal | A and B and HHH MAC | NH |
| 14512 | Wellpoint Federal | A and B and HHH MAC | VT |
| 14412 | Wellpoint Federal | A and B and HHH MAC | RI |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56550 (Billing and Coding: Panretinal (Scatter) Laser Photocoagulation) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56550: Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (Billing and Coding, effective 2026-04-01)
- Covered ICD-10-CM codes
- 275
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| E08.3211 | — |
| E08.3212 | — |
| E08.3213 | — |
| E08.3291 | — |
| E08.3292 | — |
| E08.3293 | — |
| E08.3311 | — |
| E08.3312 | — |
| E08.3313 | — |
| E08.3391 | — |
| E08.3392 | — |
| E08.3393 | — |
| E08.3411 | — |
| E08.3412 | — |
| E08.3413 | — |
| E08.3491 | — |
| E08.3492 | — |
| E08.3493 | — |
| E08.3511 | — |
| E08.3512 | — |
| E08.3513 | — |
| E08.3521 | — |
| E08.3522 | — |
| E08.3523 | — |
Procedure codes: 67228.
Coverage indications, limitations and medical necessity
Panretinal laser photocoagulation (PRP) involves extensive treatment with an argon or diode laser to the peripheral and middle portions of the retina. Photocoagulation is designed to burn and seal unwanted blood vessels, thus preventing hemorrhage. Panretinal laser photocoagulation targets the ablation of ischemic retina which in turn reduces the production of various cytokines, such as vascular endothelial growth factor (VEGF), thereby causing regression of neovascularization. Panretinal photocoagulation may also be used to ablate small areas of neovascularization on the retina. The initial treatment usually consists of approximately 1500-2000 spots of laser per eye. This is accomplished in two or more sessions. This local coverage determination (LCD) documents the indications and limitations of coverage for use of panretinal laser photocoagulation.
Indications:
Panretinal laser photocoagulation is indicated for the treatment or management of patients with proliferative or pre-proliferative diabetic retinopathy and patients with severe levels of diabetic macular edema associated with pre-proliferative retinopathy, and other proliferative retinopathies.
While panretinal laser photocoagulation greatly reduces the risk of visual loss in all states of proliferative retinopathy, treatment is withheld until the risk of visual loss outweighs the risks and side effects of the treatment.
Limitations:
Medicare coverage of panretinal laser photocoagulation using a laser is limited to management of proliferative or pre-proliferative retinopathies.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2026-04-01
- Last reviewed by the contractor
- 2018-06-01
- MCD version
- 34
- Derived from
- L28497
The contractor lists one National Coverage Determination as related: NCD 140.5 Laser Procedures. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wellpoint Federal hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L33628 cover?
Panretinal laser photocoagulation (PRP) involves extensive treatment with an argon or diode laser to the peripheral and middle portions of the retina. Photocoagulation is designed to burn and seal unwanted blood vessels, thus preventing hemorrhage. Panretinal laser photocoagulation targets the ablation of ischemic retina which in turn reduces the production of various cytokines, such as vascular endothelial growth… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33628 apply to?
Wellpoint Federal applies it to Medicare claims in CT, DN, IL, MA, ME, MN, NH, NY, QN, RI, UN, VT, WI. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33628?
The companion billing and coding article A56550 lists 275 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33628?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.