Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A59805 (Billing and Coding: Cataract Surgery) 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.
A59805: Billing and Coding: Cataract Surgery (Billing and Coding, effective 2026-07-30)
- Covered ICD-10-CM codes
- 415
- 2 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 14
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| E08.311 | — |
| E08.319 | — |
| 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 | — |
Procedure codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66987, 66988, 66989, 66991.
Coverage indications, limitations and medical necessity
A cataract is a degradation of the optical quality of the crystalline lens that affects vision. Cataracts cause an opacity or cloudiness in the lens of the eye(s) which blocks the passage of light through the lens. 6
Cataracts occur frequently as a progressive age-related disease and is the leading cause of blindness worldwide of all ethnic and racial backgrouds. 6 More than half of all Americans age 80 or older either have cataracts or have had surgical treatment of cataracts. 2 Cataract is the leading cause of visual impairment among Americans of all studied ethnic and racial backgrounds. 3 The number of people in the United States with cataracts is expected to double from 24.4 million to approximately 50 million in the next 30 years. 2,6 Most cataract development is related to aging, and it can occur in one or both eyes. As part of the aging process, the lens increases in thickness and weight causing hardening and compression on the nucleus eventually developing a yellow-brown color that changes the transparency of the lens. Cataracts have several different types that have their own anatomical location, pathology, and risk factors which increase with each decade of life starting around age 40. 6 Risk factors that can increase cataract development may include smoking, ultraviolet β radiation exposure, complications of diabetes, and drug and/or alcohol use. 2
Medicare coverage for cataract extraction, and cataract extraction with intraocular lens implant, is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This policy defines coverage and describes criteria necessary to justify the performance of cataract surgery.
Coverage Indications
In the clinical presence of cataract(s), cataract surgery is considered medically necessary when the following conditions or circumstances exist, and are clearly documented in the medical record:
• After comprehensive medical eye evaluation 6 AND
• Consideration of the risk factors for undergoing the planned anesthesia, 6 AND
• Informed consent from the patient or the patient’s health care power of attorney after discussing the risks, benefits, and expected outcomes of surgery, including the anticipated refractive outcome, 6 AND
• Outcome measures of cataract surgery such as visual acuity, accuracy of refractive correction, occurrence of significant operative and postoperative complications shall be recorded post-operatively, 4,6 AND
• The cataract is causing visual impairment that is not correctable with a tolerable change in glasses or contact lenses, resulting in the inability to perform Activities of Daily Living such as, but not limited to, driving, reading, watching television, and/or meeting vocational or recreational needs, 4 OR
• The lens opacity interferes with optimal diagnosis or management of posterior segment conditions (e.g., diabetic retinopathy or macular degeneration), 6 OR
• As a treatment of vision threatening cataract induced complications (e.g., the lens induces or risks angle closure , uveitis, dislocation of the lens), 6 OR
• During vitrectomy procedures, the lens interferes with the performance of vitreoretinal surgery, as in the case of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy, 6 OR
• There is a high probability of accelerating cataract development because of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation, 6 OR
• There is clinically significant anisometropia or aniseikonia that exists because of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity), 6 OR
• There is lens injury with potential lens swelling (traumatic cataract) 6
Please refer to NCD 10.1-Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery for information on pre surgery evaluations.
Coverage Limitations
• Cataract surgery is not reasonable and necessary when all the above criteria are not fulfilled. AND
• Cataract surgery can only be performed once for the same eye. 6
Complex cataract surgery
Coverage Indications:
Complex cataract surgery will be considered medically reasonable and necessary when there is one of the following:
• A miotic pupil that will not dilate sufficiently requiring the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye, 14 OR
• Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens, 15 OR
• Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis, 6 OR
• Mature cataract requiring dye for visualization of capsulorrhexis. 6
Refer to CMS IOM Pub. 100-04, Medicare Claims Processing Manual , Chapter 32, Section 120, for CMS guidelines on IOL insertion benefit following cataract surgery.
Summary of evidence (opening)
According to the American Academy of Ophthalmology (AAO) 2021 et al, 6 cataract surgery is primarily recommended for visual function that no longer meets the patient’s needs and should be considered based on visual acuity, visual impairment, and potential for functional benefits. The preoperative evaluation should not be solely based on a visual Snellen exam, but should include an ophthalmic evaluation, patient-centered visual function exams and questionnaires, and patient education about treatment options prior to consent. The AAO has set characterizations to ensure that improved visual function, physical function, and mental health is restored after cataract surgery. Cataract surgery is also known to decrease intraocular pressure (IOP) after phacoemulsification cataract surgery in patients with or without glaucoma. Alternatives to cataract surgery and management of cataract are very few. Miller, et al 6 displays outcomes from studies that prove cataract surgery to be effective when considered in the AAO’s practice patterns for cataract surgery guidelines. Across the studies mentioned, patients have improved corrected distance visual acuity (CDVA) scores, increased visual acuity, and were overall satisfied with the results of their surgery and improvement in quality of life. The only major potentially eye-threatening complications of cataract surgery are infectious endophthalmitis, toxic anterior segment syndrome (TASS), toxic posterior segment syndrome (TPSS), suprachoroidal hemorrhage, cystoid macular edema (CME), persistent corneal edema, IOL dislocation, secondary glaucoma, diplopia, and blindness those these complications are rare. Comparing studies have shown that patients who receive cataract surgery in both eyes have greater functional improvement than those that had surgery in 1 eye.
According to the AAO 2021 et al, 6 symptomatic cataract is a surgical disease and the standard of care in cataract surgery in the U.S. is a small-incision phacoemulsification with foldable IOL implantation. Cataracts are the leading cause of treatable blindness among all races worldwide. The risk of developing cataracts increases beginning at age 40. As part of the aging process, the lens increases in thickness and weight causing hardening and compression on the nucleus. The lens eventually develops a yellow-brown color that changes the transparency. To confirm that a cataract is causing visual impairment rather than another ocular or systemic condition, a comprehensive evaluation should be conducted. Cataract surgery is the primary management of significant visual impairment. The complexity of cataract surgery requires special training, clinical experience, and judgment that are necessary to evaluate the medical, ocular, and psychosocial factors used to determine the appropriateness and timing of surgery. There are no pharmacologic treatments to eliminate cataracts. Visual function plays a major role in physical performance, mental and emotional well-being, and mobility for the elderly. Visual impairment increases the risk for falls and hip fractures in the elderly. Improved vision can reduce the fear of falling, which is 1 of the listed outcomes for characterized improvement in mental health and emotional well-being in the elderly. The indications, contraindications, and complications for cataract surgery are the same. Multiple studies that were used for the AAO’s preferred practice pattern show that CDVA scores improved, over 90% of patients, postoperatively, had improved visual acuity and improvement in VF-14 scores, and that the strongest preoperative indicator for visual function improvement is the glare disability test at low and medium spatial frequencies. Overall, cataract surgery is safe and effective for young adults and the elderly population. It reaches its goal of improving visual function and enhancing quality of life. The preferred practice patterns set by AAO, have clear guidelines that are suited to promote optimal health and a clear path of treating adult cataract patients.
In patients with bilateral cataracts, determining the appropriate time interval between the first eye surgery and the second eye surgery is complex and influenced by several factors. In recent years, studies in Canada, Europe and other countries have concluded immediate sequential bilateral cataract surgery (ISBCS) is safe, effective, and of economic benefit. 6 Benefits of ISBCS include decreased costs to the patient in travel and office visits, quicker improvement in patients self-reported visual function, and have similar results to performing the first eye surgery and delayed second eye surgery. There are prospective and retrospective studies showing similar results in CDVA, uncorrected distance visual acuity (UDVA) and refractive outcomes with ISBSC compared with delayed bilateral surgery.
The reported drawbacks of performing ISCBS include the inability to adjust the IOL power in the second eye based on the results of the first eye, and bilateral dysphotopsia. While cases are rare, the most serious potential complication is bilateral blindness due to endophthalmitis or toxic anterior segment syndrome (TASS). This most often occurs when recommended guidelines of separate surgical setups is not followed. When recommended guidelines are followed which include an intracameral antibiotic, there have been no reports of bilateral endophthalmitis or TASS. 6 The American Academy of Ophthalmology IRIS ® Registry database showed in one prospective study that the rate of endophthalmitis after ISBCS and delayed sequential bilateral cataract surgery postoperatively, was not “statistically significant”. 6
The contractor cites 15 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2024-10-13
- Current revision effective
- 2026-07-30
- Last reviewed by the contractor
- 2026-06-16
- MCD version
- 5
The contractor lists 4 National Coverage Determinations as related: NCD 10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery, NCD 80.10 Phaco-Emulsification Procedure - Cataract Extraction, NCD 80.12 Intraocular Lenses (IOLs), NCD 80.8 Endothelial Cell Photography. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Other related documents: A59904 (Response to Comments).
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 Wisconsin Physicians Service Insurance Corporation 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 L39905 cover?
A cataract is a degradation of the optical quality of the crystalline lens that affects vision. Cataracts cause an opacity or cloudiness in the lens of the eye(s) which blocks the passage of light through the lens. 6 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 L39905 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. 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 L39905?
The companion billing and coding article A59805 lists 415 ICD-10-CM codes in 2 groups 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 L39905?
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.