Medical Necessity Determination for CPT 66984 and 65820
DECISION
Based on the available documentation, CPT 66984 (phacoemulsification with IOL insertion) MEETS medical necessity criteria, but CPT 65820 (goniotomy) CANNOT BE DETERMINED due to insufficient clinical documentation. 1
RATIONALE
CPT 66984 - Cataract Surgery with IOL (APPROVED)
The cataract surgery meets objective medical necessity criteria based on visual acuity of 20/300, which exceeds the threshold of 20/50 or worse required by Aetna policy and American Academy of Ophthalmology guidelines. 2, 1
Objective Criteria Met:
- Visual acuity 20/300 clearly meets the 20/50 or worse threshold for medically necessary cataract surgery 1
- Age-related nuclear cataract diagnosis (H25.11) is documented 2
- Nuclear cataracts typically progress slowly and affect distance vision, with no pharmacological treatment available to reverse or retard progression 2, 1
Missing Documentation (Critical Gaps):
- No comprehensive eye examination documented - required by Aetna criteria A.1 1
- No subjective assessment of visual disability documented (impact on driving, reading, daily activities) - required by Aetna subjective criteria 1
- No documentation of patient education regarding risks, benefits, and alternatives - required by Aetna educational criteria 1
- No confirmation that cataract is the limiting factor for visual improvement versus other pathology - required by Aetna objective criteria ii 1
- No biometry studies documented (A-scan, optical coherence biometry, IOL power calculation) - considered medically necessary for routine pre-operative work-up 1
CPT 65820 - Goniotomy (CANNOT BE DETERMINED)
The medical necessity for goniotomy cannot be established due to complete absence of documentation supporting this procedure for the patient's diagnosed condition of primary open-angle glaucoma (POAG). 2
Critical Documentation Deficiencies:
1. Wrong Glaucoma Type for Standard Goniotomy Indications:
- Patient has primary open-angle glaucoma (H40.1114), not angle-closure glaucoma 3, 4
- Goniotomy is primarily indicated for angle-closure disease with synechial closure or plateau iris syndrome 2
- The American Academy of Ophthalmology guidelines indicate goniotomy is used for angle-closure management, particularly after failed iridotomy or with extensive peripheral anterior synechiae 2
2. No Gonioscopy Documentation:
- Gonioscopy is essential to determine angle anatomy and justify goniotomy 2
- No documentation of angle closure, peripheral anterior synechiae, or trabecular meshwork visualization 2
- Cannot determine if angle is open, narrow, or closed without gonioscopy 2
3. No IOP Control Documentation:
- No baseline IOP measurements documented 3, 4
- No documentation of failed medical management or number of glaucoma medications 3, 4, 5
- Glaucoma stage listed as "indeterminate" - insufficient to justify surgical intervention 2
4. Missing Visual Field and Optic Nerve Assessment:
- No visual field testing documented to assess glaucoma severity 2
- No optic nerve examination or cup-to-disc ratio documented 2
- Cannot determine if glaucoma threatens vision or requires surgical intervention 2
Evidence for Goniotomy in POAG (When Properly Documented):
- Recent studies show goniotomy can be effective for POAG when combined with cataract surgery, achieving 26-46% IOP reduction 3, 4
- 120-degree goniotomy is as effective as 360-degree with lower hyphema rates (safer profile) 3
- However, these studies required documented baseline IOP, medication burden, and gonioscopy findings - none of which are present in this case 3, 4
SPECIFIC CRITERIA ASSESSMENT
Aetna Clinical Policy Bulletin #0508 Compliance:
| Criterion | Status | Evidence |
|---|---|---|
| A.1 Comprehensive eye examination | ❌ NOT DOCUMENTED | Required pre-operative [1] |
| B-E Biometry studies (A-scan, IOL calculation) | ❌ NOT DOCUMENTED | Required for routine work-up [1] |
| Subjective criteria - Patient perception of visual disability | ❌ NOT DOCUMENTED | Required for VA 20/50 or worse [1] |
| Objective i - VA 20/50 or worse | ✅ MET (20/300) | Documented [1] |
| Objective ii - Cataract is limiting factor | ❌ NOT DOCUMENTED | No confirmation other pathology excluded [1] |
| Objective iii - Medical/mental health permits surgery | ❌ NOT DOCUMENTED | No medical clearance noted [1] |
| Educational - Patient educated on risks/benefits | ❌ NOT DOCUMENTED | No informed consent documentation [1] |
COMMON PITFALLS IN THIS CASE
1. Retrospective Documentation Gaps:
- RETRO cases require complete documentation at time of service 1
- Operative note alone is insufficient without supporting pre-operative evaluation 2, 1
2. Goniotomy for POAG Without Justification:
- Goniotomy in POAG is a newer indication requiring specific documentation of angle anatomy and failed medical management 3, 4
- Cannot assume medical necessity based solely on diagnosis code 2
3. Missing MDO (Medical Decision-Making) Notes:
- As noted in the query, no MDO testing notes or patient health status documentation 1
- This is critical for establishing both subjective and objective criteria 1
RECOMMENDATIONS FOR APPROVAL
For CPT 66984 (Cataract Surgery):
APPROVE with documentation of:
Request addendum documenting:
- Subjective visual complaints and functional impact
- Comprehensive eye examination findings
- Patient education and informed consent
- Biometry studies performed
For CPT 65820 (Goniotomy):
DENY or REQUEST ADDITIONAL DOCUMENTATION:
Required documentation for reconsideration:
- Gonioscopy findings showing angle anatomy and degree of closure 2
- Baseline IOP measurements and number of glaucoma medications 3, 4
- Visual field testing and optic nerve assessment showing glaucoma severity 2
- Justification for goniotomy in POAG - either failed medical management or specific angle pathology 3, 4
- Medical decision-making note explaining rationale for combined procedure 5
Alternative consideration: If angle-closure component exists (not documented), goniotomy may be appropriate for mixed-mechanism glaucoma 5, 6, but this requires gonioscopy confirmation 2