YAG capsulotomy (66821) is considered medically necessary for the following indications:

1. Medically necessary treatment and/or diagnosis of posterior eye disease obscured by posterior capsule opacification (366.50, 366.52, 366.53)
   
   
2. Vision loss due to:
   
   
   • Decreased light transmission (visual acuity <20/30) after other causes of loss of acuity have been ruled out
     
     
   • Increased glare-test results must show, a) consensual light testing decreases the visual acuity by two lines, or b) decrease in two lines of visual acuity in glare tester.

YAG capsulotomy reported for indications other than those listed above will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

This procedure is seldom indicated in less than three months following cataract surgery. If a claim is submitted for procedure 66821 within three months of cataract surgery, documentation justifying the need for the procedure is required to support medical necessity.

When a series of procedures is planned for the removal of a posterior cataract, it will be covered as a single procedure. (See Highmark Medical Policy Bulletin S-49 for additional information on eye procedures done in stages).

A second procedure performed on the same patient, on the same eye, that is not part of a series may be submitted for payment by individual consideration.

Description

YAG capsulotomy (66821) is the incision of the posterior capsule, which serves as a boundary between the lens and the vitreous humor of the eye. This allows the capsule to retract and no longer serve as an obstruction to the passage of light through the media to the retina. The incision is performed with an Yttrium Aluminum Garnet (YAG) laser. It is usually, but not always, performed on an out-patient basis.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.