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    v1.0.30
    OpenPayerPolicy UpdatesOphthalmology/OptometryAnthem Cataract Surgery Coverage Update | OpenPaye…
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    CurrentAnthemPolicy CG-SURG-40

    Cataract Removal Surgery for Adults

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    This policy governs when cataract extraction is medically necessary for adults with visually significant cataracts, lens-related ophthalmic disease, or a need for lens removal to visualize the retina or support another eye procedure. It does not address congenital cataracts.

    Policy Summary
    PayerAnthem
    PolicyCataract Removal Surgery for Adults
    Policy CodePolicy CG-SURG-40
    Change TypeRevised
    Effective DateOct 1, 2026
    Last ReviewAug 13, 2026
    Next Review DateN/A
    Key ActionApply the medical necessity criteria to confirm that adult cataract removal meets at least one qualifying pathway before approving coverage.
    SourceLink
    POLICY UPDATE CHANGES

    A new Members and Families section was added in the 2026 review.

    The medically necessary vision-loss criterion was modified in 2022 to focus on functional impairment rather than a specified Snellen visual acuity threshold.

    The medical necessity indications were revised in 2018 to replace Snellen criteria with criteria addressing functional impairment.

    CPT codes 66987 and 66988 were added in the 2020 coding update.

    3Primary coverage pathways for medically necessary cataract removal

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5Daily or vocational activities specifically identified as potentially impaired
    10CPT procedure codes listed
    5HCPCS and local device codes listed
    4ICD-10-PCS codes listed
    3Explicit not-medically-necessary scenarios

    Medical Necessity Criteria

    Medically Necessary Cataract Removal

    Cataract removal surgery in adults is considered medically necessary when ANY of the following pathways applies:

    ANY of the following

    • Visually significant cataract

      • The lens displays signs of cataract formation.
      • The cataract is causing symptomatic impairment of visual function that is not correctable with a tolerable change in glasses or contact lenses.

      • Vision loss interferes with one or more of the following

        • Reading.
        • Viewing television.
        • Driving.
        • Meeting vocational or recreational needs.
        • Other daily activities.
      • Other eye disease(s) have been ruled out as the primary cause of decreased visual function, including, but not limited to, macular degeneration or diabetic retinopathy.
      • Surgery is reasonably expected to result in improved visual function.

    • Underlying lens-related or other ophthalmologic disease for which cataract removal is indicated

      • Phacomorphic glaucoma.
      • Phacolytic glaucoma.
      • Phacoanaphylactic endophthalmitis.
      • Dislocated or subluxated lens.
      • Angle closure glaucoma.
      • Elevated intraocular pressure associated with a diagnosis of plateau iris configuration.
      • Uncontrolled pseudoexfoliation glaucoma.

    • Lens removal is needed for either of the following

      • To allow better visualization of the retina.

      • As a component of another surgical procedure

        • Diabetes with diabetic retinopathy requiring photocoagulation management through clear media.
        • To monitor progression of glaucoma where opaque media limits visualization of the optic nerve or visual field assessment.
        • Preparation for vitrectomy.
        • Preparation for surgical repair of retinal detachment.

    Not Medically Necessary

    Cataract removal surgery in adults is considered not medically necessary when ANY of the following applies:

    ANY of the following

    • The medically necessary criteria specified above are not met.
    • Glasses or visual aids provide satisfactory functional vision.
    • Visual function is not compromised by the cataract.

    Congenital cataracts are outside the scope of this document. This document addresses cataract extraction in adults for visually significant cataracts, when lens removal is needed to allow better visualization of the retina, or when it is used as a component of another surgical procedure.

    Cataract removal is not medically necessary when the applicable medical-necessity criteria are not met. It is also not medically necessary when glasses or other visual aids provide satisfactory functional vision or when the cataract does not compromise visual function.

    Applicable Procedure and Diagnosis Codes

    CPT codes when services may be medically necessary when criteria are metCPTCovered
    66830Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy).
    66840Removal of lens material; aspiration technique, 1 or more stages.
    66850Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration.
    66852Removal of lens material; pars plana approach, with or without vitrectomy.
    66920Removal of lens material; intracapsular.
    66940Removal of lens material; extracapsular (other than 66840, 66850, 66852).
    66982Extracapsular 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; without endoscopic cyclophotocoagulation.
    66983Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure).
    66984Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation.
    66985Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal.
    1–10 of 12
    1/2
    HCPCS codes when services may be medically necessary when criteria are metHCPCSCovered
    C1780Lens, intraocular (new technology).
    Q1004New technology intraocular lens category 4 as defined in Federal Register notice.
    Q1005New technology intraocular lens category 5 as defined in Federal Register notice.
    V2630Anterior chamber intraocular lens.
    V2631Iris supported intraocular lens.
    V2632Posterior chamber intraocular lens.
    ICD-10 Procedure codes when services may be medically necessary when criteria are metICD-10Covered
    08DJ3ZZExtraction of right lens, percutaneous approach.
    08DK3ZZExtraction of left lens, percutaneous approach.
    08RJ3JZReplacement of right lens with synthetic substitute, percutaneous approach.
    08RK3JZReplacement of left lens with synthetic substitute, percutaneous approach.
    ICD-10 DiagnosisICD-10
    No codes listed
    Procedure codes when criteria are not metCPTNot Covered
    66830, 66840, 66850, 66852, 66920, 66940, 66982, 66983, 66984, 66985, 66987, 66988The procedure codes listed above are not medically necessary when criteria are not met or when a situation designated in the Clinical Indications section as not medically necessary applies.

    Medical Necessity and Documentation Risk

    Denial Risk

    Failure to Meet Medical Necessity Criteria

    Document that the applicable medical-necessity criteria are met before recommending or billing adult cataract removal surgery. Failure to meet the criteria creates denial risk, including when glasses or visual aids provide satisfactory functional vision or when the cataract does not compromise visual function.

    • Denial risk: Cataract removal surgery is not medically necessary when the specified criteria are not met.
    • Do not proceed without supporting documentation when satisfactory functional vision is achieved with glasses or visual aids.
    • The procedure is not medically necessary when visual function is not compromised by the cataract.

    Clinical Background

    A cataract is clouding of the eye’s natural lens that can impair visual function. Cataract extraction generally removes the cloudy lens and usually replaces it with an artificial lens to improve vision and daily functioning when the cataract interferes with activities. Lens removal may also be performed to improve visualization of the retina or as part of another ophthalmic procedure.

    Ophthalmic Terms

    Cataract
    TermCataract
    DefinitionCloudiness of the natural lens inside the eye that can blur vision.
    Potential effectA cataract can blur vision.
    Cornea
    TermCornea
    DefinitionThe clear, transparent cover over the iris and pupil on the front part of the eye.
    FunctionThe cornea is the first part of the eye that bends, or refracts, light and provides most of the eye's focusing power.
    Policy Summary
    PayerAnthem
    PolicyCataract Removal Surgery for Adults
    Policy CodePolicy CG-SURG-40
    Change TypeRevised
    Effective DateOct 1, 2026
    Last ReviewAug 13, 2026
    Next Review DateN/A
    Key ActionApply the medical necessity criteria to confirm that adult cataract removal meets at least one qualifying pathway before approving coverage.
    SourceLink
    On This Page
    Medical Necessity CriteriaApplicable Procedure and Diagnosis CodesMedical Necessity and Documentation RiskClinical BackgroundOphthalmic Terms
    Crystalline (natural) lens
    TermCrystalline (natural) lens
    DefinitionThe eye's natural lens that bends, or refracts, light to provide some of the focusing power of the eye.
    FunctionThe natural lens can change shape, allowing the eye to focus on different distances.
    Glaucoma
    TermGlaucoma
    DefinitionA disease characterized by destruction of the nerve fiber layer of the optic disc.
    Affected structureThe nerve fiber layer of the optic disc.
    Optic nerve
    TermOptic nerve
    DefinitionThe nerve that carries images of what is seen from the eye to the brain.
    Primary roleCarries visual information from the eye to the brain.
    Retina
    TermRetina
    DefinitionThe light-sensitive layer of tissue that lines the inside of the eye.
    FunctionSends visual messages through the optic nerve to the brain.