Prior authorization for cataract surgery

Cataract surgery is common and effective, which is why reviewers focus less on the lens and more on the patient: is the loss of vision caused by the cataract, has a change of glasses been tried, and does it limit what the patient needs to do? A request that answers those three points is usually straightforward.

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What reviewers look for

Best-corrected visual acuity in each eye, after a current refraction, not just unaided or pinhole acuity.
Glare testing or contrast findings when the complaint is glare, night driving or bright light, since acuity in a dark room can understate the problem.
Slit-lamp description of the cataract: type and density, such as nuclear sclerosis, cortical or posterior subcapsular opacity.
A fundus and macular assessment showing that the cataract, not retinal or optic nerve disease, explains the loss of vision, or stating what else is present and its expected effect.
Functional impairment in the patient's own terms: driving, reading, work tasks, falls, recognising faces.
That a change of glasses was tried or would not help.
For the second eye: symptoms from imbalance between the eyes, the acuity in that eye, and the result of the first operation.

Letter structure

Lead with the eye and procedure, then the diagnosis code with laterality. Cataract extraction with intraocular lens implant is commonly coded 66984, and age-related nuclear cataract is H25.11 for the right eye, H25.12 for the left and H25.13 for both. Follow with acuity and glare results, the lens findings, the macular assessment, the effect on daily life, and the refraction history. Close with the planned eye and the expected benefit stated cautiously.

Example

Example request excerpt: first eye

Request: Right cataract extraction with intraocular lens (66984).
Diagnosis: Age-related nuclear cataract, right eye (H25.11).

[Patient initials], 71, reports 18 months of worsening blur and severe glare from oncoming headlights, and has stopped driving after dark. Difficulty reading medicine labels.

Best-corrected acuity after refraction today: right 6/18, left 6/9. Updated glasses prescribed 8 months ago gave no useful improvement on the right.

Slit lamp: dense nuclear sclerosis, right greater than left. Dilated fundus examination and macular OCT: no macular pathology in either eye.

The reduction in right vision is explained by the cataract, limits driving and reading, and has not responded to a change of spectacles. Surgery is expected to improve acuity and glare symptoms.

Invented example for illustration. Not a real patient.

Acuity notation differs between clinics. Use the notation your practice uses consistently in the note and the letter.

Why cataract requests are questioned

Acuity looks too good. If acuity is near normal but glare is disabling, include the glare test result and the specific tasks affected.
Another cause is not addressed. Macular degeneration, diabetic eye disease or glaucoma can limit the benefit. Document the assessment and why surgery is still expected to help.
No refraction. A reviewer will ask whether glasses would solve the problem. Write the refraction date and result into the chart note.
Second eye without its own case. The second eye needs its own acuity, symptoms and reasons, not a reference to the first.

How ClearPass helps ophthalmology clinics

Ophthalmology has its own group of guided templates. From the clinic note, typed or transcribed, ClearPass drafts the cataract justification in the length you choose, with ICD-10 and procedure codes and laterality carried through from the note. If the note gives acuity but no refraction date, it asks. It argues clinical necessity from the documented findings, names no payer rule outside the country with a rules pack, and never states that the procedure will be approved. You review it and file it. For everyday clinic notes see AI scribe for ophthalmology.

What ClearPass does not do

It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
It is not a medical device and does not make clinical decisions. It is a documentation aid.
It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Is there a fixed acuity threshold for cataract surgery?

Some criteria use one, many look at functional impairment alongside acuity. Document both, and include glare testing where glare is the main complaint.

How do I code the second eye after the first has had surgery?

Code the cataract in the eye being operated on, for example H25.12 for the left. The operated eye can be shown with the code for presence of an intraocular lens, Z96.1, where that is useful.

Can it read the biometry printout?

You can photograph a report and the clinical details are read into the note. Remove patient identifiers from the image first, since photos are not auto-redacted.

What does ClearPass cost?

The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.

Try it on your next clinic day

The full product for 7 days, with no card and no automatic charge. Then $78 a month or $858 a year. Pricing details.

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