Page 1 of 1 Origination Date: 4/08 Revision Date(s): 4/09, 2/11, 2/12, 12/12, 11/13, 11/14 Developed By: Medical Criteria Committee

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1 Page 1 of 1 Approved: Mary Engrav, MD Date: 12/03/2014 Description: Aphakia is an absence of the lens in the eye. It may occur congenitally or from trauma, but is most commonly caused by extraction of a cataract. This lens is generally replaced after cataract surgery with the implantation of an intraocular lens (IOL). Intraocular lenses (of any type) are designed to replace the defective (e.g. traumatized, cataracts, or other disease) human crystalline lens. The IOL is usually inserted during the same surgery as the natural lens is removed. At times, the IOL may be inserted later in a secondary, separate operation. There are several types of intraocular lenses that are currently used: Conventional Intraocular Lens (IOL) A conventional intraocular lens (IOL) is a small, lightweight clear disk that replaces the eye's natural lens. Use of a conventional IOL causes presbyopia. Presbyopia is when the eye loses the ability to focus clearly on objects at varying distances (near and far). Presbyopia Correcting and Accommodative Intraocular Lens (IOL) A presbyopia correcting intraocular lens (P-IOL), otherwise known as an accommodative intraocular lens (A- IOL), can provide the same results in correcting presbyopia as a conventional IOL used with eyeglasses or contact lenses. Astigmatism Correcting Intraocular Lens (A-C IOL) An astigmatism correcting intraocular lens (A-C IOL) can provide the same results in correcting astigmatism as a conventional IOL used with eyeglasses or contact lenses. I. Criteria: CWQI HCS-0043 (This criteria is consistent with CMS guidelines for Intraocular Lenses) A. COVERED 1. Moda Health will cover a conventional IOL to plan limitations following cataract surgery. B. NOT COVERED 1. Presbyopia correcting IOLs (V2788) and astigmatism correcting IOLs (V2787) or any other IOL that alters the refractive character of the eye will NOT be covered. These intraocular lenses are not the least costly alternative and therefore, not medically necessary. In addition, surgery to alter the refractive character of the eye is typically not a covered benefit. Check specific plan benefits.

2 Page 2 of 1 Medicare Reference: NCD: Intraocular Lenses Applicable CPT/HCPC Codes: CPT/HCPC Description Codes Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal Exchange of intraocular lens C1780 Lens, intraocular (new technology) Q1003 New technology intraocular lens category 3 (reduced spherical aberration)(code deleted 04/01/2011) V2630 Anterior chamber intraocular lens V2631 Iris supported intraocular lens V2632 Posterior chamber intraocular lens V2787 Astigmatism correcting function of intraocular lens V2788 Presbyopia correcting function of intraocular lens Applicable ICD-9 Codes: ICD-9 Codes Diagnosis Infantile, juvenile and presenile cataract Senile cataract Traumatic cataract Cataract secondary to ocular disorders

3 Page 3 of Cataract associated with other disorders After-cataract Other cataract Unspecified cataract Anisometropia Aphakia Subluxation of the lens Anterior dislocation of lens Posterior dislocation of lens Congenital cataract and lens anomalies Mechanical complication of other specified prosthetic device, implant, and graft, due to ocular lens implant V43.1 Organ or tissue replaced by other means, lens V45.61 Cataract extraction status Applicable ICD-10 Codes: ICD-10 Codes Diagnosis E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E10.36 Type 1 diabetes mellitus with diabetic cataract E11.36 Type 2 diabetes mellitus with diabetic cataract E13.36 Other specified diabetes mellitus with diabetic cataract H25.10 Age-related nuclear cataract, unspecified eye H Cortical age-related cataract, unspecified eye H25.20 Age-related cataract, morgagnian type, unspecified eye H Anterior subcapsular polar age-related cataract, unspecified eye H Posterior subcapsular polar age-related cataract, unspecified eye H Other age-related incipient cataract, unspecified eye H Combined forms of age-related cataract, unspecified eye H25.89 Other age-related cataract H25.9 Unspecified age-related cataract H Unspecified infantile and juvenile cataract, unspecified eye H26.09 Other infantile and juvenile cataract H Infantile and juvenile cortical, lamellar, or zonular cataract, unspecified eye H Infantile and juvenile nuclear cataract, unspecified eye H Anterior subcapsular polar infantile and juvenile cataract, unspecified eye

4 Page 4 of 1 H Posterior subcapsular polar infantile and juvenile cataract, unspecified eye H Combined forms of infantile and juvenile cataract, unspecified eye H Unspecified traumatic cataract, unspecified eye H Localized traumatic opacities, unspecified eye H Partially resolved traumatic cataract, unspecified eye H Total traumatic cataract, unspecified eye H26.20 Unspecified complicated cataract H Cataract with neovascularization, unspecified eye H Cataract secondary to ocular disorders (degenerative) (inflammatory), unspecified eye H Glaucomatous flecks (subcapsular), unspecified eye H26.8 Other specified cataract H26.30 Drug-induced cataract, unspecified eye H26.40 Unspecified secondary cataract H Soemmering's ring, unspecified eye H Other secondary cataract, unspecified eye H26.8 Other specified cataract H26.9 Unspecified cataract H27.03 Aphakia, bilateral H Subluxation of lens, unspecified eye H Anterior dislocation of lens, unspecified eye H Posterior dislocation of lens, unspecified eye H28 Cataract in diseases classified elsewhere H52.31 Anisometropia Q12.0 Congenital cataract Q12.1 Congenital displaced lens Q12.3 Congenital aphakia Q12.4 Spherophakia Q12.8 Other congenital lens malformations Q12.9 Congenital lens malformation, unspecified T85.29XA Other mechanical complication of intraocular lens, initial encounter Z96.1 Presence of intraocular lens Z98.49 Cataract extraction status, unspecified eye Review Date Revisions Effective Date 12/2012 Annual Review: Added table with review date, 01/01/2013 revisions, and effective date. 11/13 Annual Review: No changes 11/27/ /2014 Annual Review: No changes 12/3/ /2015 Added ICD-9 and ICD-10 codes and Medicare Reference 07/2015

5 Page 5 of 1 References: Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) for intraocular lenses (IOLs) (80.12). Effective 5/19/97. Accessed February 10, 2010 at: Menapace R, Findl O, Kriechbaum K, et al. Accomodating intraocular lenses: a critical review of present and future concepts. Graefes Arch Clin Exp Ophthalmol Apr;245(4): Mendicute J, Irigoyen C, Aramberri J, et al. Foldable toric lens for astigmatism correction in cataract patients. J Cataract Refract Surg Apr;34(4): Tonekaboni K, Whitsett AJ. The IOL horizon: accommodative intraocular lenses. Optometry Mar;76(3): American Academy of Ophthalmology. Cataract in the adult eye. Preferred practice pattern American Academy of Ophthalmology. Accessed July 21, Available at URL address: Physician Advisors