Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Partial Coherence Interferometry

Policy #:07.13.08e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Partial coherence interferometry is considered medically necessary and, therefore, covered for the preoperative determination of the power of the intraocular lens (IOL) to be implanted after cataract removal.

Partial coherence interferometry for reasons other than preoperative determination of the power of the IOL is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Generally, it is expected that the health care professional who is performing the cataract surgery will perform the optical coherence biometry (OCB).

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, partial coherence interferometry is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for optical biometry by partial coherence interferometry.

Description

During pre-cataract surgery evaluation, calculations such as axial eye length, corneal radius, and anterior chamber depth are made to determine the appropriate power of the pseudophakic intraocular lens (IOL) to be implanted. These calculations must be accurate in order to promote optimal postoperative refraction. The axial length of the eye can be measured with ultrasound (applanation or immersion), although user error in the placement of the transducer against the surface of the eye may result in a significant postoperative refractive error. Keratometry is most often used to measure corneal radius. The determination of anterior chamber length is made using slit-lamp illumination.

Partial coherence interferometry, also known as optical (ocular) coherence biometry (OCB) or laser Doppler interferometry, is a more recent technique for measurement of the axial length of the eye. This procedure uses a laser Doppler function to calculate the echo delay and the intensity of infrared light that is reflected back from inner eye surfaces. Because it does not require direct contact with the eye, partial coherence interferometry is a more comfortable technique; it also avoids the refractive errors that can occur with transducer misplacement.
References


Fontes BM, Fontes BM, Castro E. Intraocular lens power calculation by measuring axial length with partial optical coherence and ultrasonic biometry. Arq Bras Oftalmol.2011;74(3):166-70.

Nemeth G, Hassan Z, Szalai E, et al. Comparative analysis of white-to-white and angle-to-angle distance measurements with partial coherence interferometry and optical coherence tomography. J Cataract Refract Surg.2010;36(11):1862-1866.

Novitas Solutions. A53131: Ophthalmic biometry for intraocular lens (IOL) power calculation. [Novitas Solutions Web site]. 10/01/2015. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53131&ver=2&ContrId=323&ContrVer=1&CntrctrSelected=323*1&DocID=A53131&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed January 2, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. IOLMaster. 510(k) Summary. [FDA Web site]. 03/20/00. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/K993357.pdf. Accessed January 2, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. IOLMaster 500. 510(k) Summary. [FDA Web site]. 11/03/10. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf10/K101182.pdf. Accessed January 2, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

92136


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A




HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Partial Coherence Interferometry
Description: ICD-10 Codes




Policy History

Revisions from 07.13.08e:
04/23/2018This version of the policy will become effective 04/23/2018. The intent of this policy remains unchanged.

The following ICD-10 CM codes have been added to this policy:
H26.411 Soemmering's ring, right eye
H26.412 Soemmering's ring, left eye
H26.413 Soemmering's ring, bilateral
H26.419 Soemmering's ring, unspecified eye
H27.00 Aphakia, unspecified eye


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 04/23/2018
Version Issued Date: 04/23/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.