LCD L34064: Panretinal (Scatter) Laser Photocoagulation

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 or xenon arc is limited to management of proliferative or pre-proliferative retinopathies.

Panretinal laser photocoagulation is usually performed in two or more sessions (staged surgery). Payment may be made only once during the global period of the initial procedure. Reimbursement for subsequent sessions in the postoperative period of the initial procedure is included in the allowance of the initial procedure.

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 to process their claims.

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 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.) However, reimbursement will not be allowed to non-physician practitioners for performance of the procedure addressed in this policy.

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