LCD L34512: Corneal Pachymetry

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 involving the cornea

• Preoperative assessment of the health of the cornea in Fuch's dystrophy

• Assessment of corneal thickness after ocular trauma

• Assessment of corneal thickness in suspected glaucoma following the diagnosis of increased intraocular pressure AND prior to the initiation of a treatment regimen for glaucoma

It is expected that a service for a corneal thickness measurement following the diagnosis of increased intraocular pressure will be performed once in a lifetime per beneficiary, unless there has been interval corneal trauma or surgery following a previous measurement. The lifetime limit ONLY applies for measurements done to assess corneal thickness, in conjunction with a glaucoma diagnosis. The limit does not apply in cases where the assessment of corneal thickness is required after ocular trauma (surgical or accidental) has been sustained, including the management of bullous keratopathy resulting from surgical or accidental trauma, or in Fuch’s dystrophy.

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed only by ophthalmologists 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). When the change in the corneal shape results from a previous partial or complete corneal transplant, Medicare will cover a pachymetry service.

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

Other Comments:

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 Comprehensive Outpatient Rehabilitation Facilities (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.

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