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| Medical Policy: | O-4-015 |
| Topic: | Intraocular Lens |
| Section: | Orthotic & Prosthetic Devices |
| Effective Date: | January 6, 2014 |
| Issue Date: | August 6, 2018 |
| Last Reviewed: | July 2018 |
An intraocular lens is a hard type of artificial lens which is surgically implanted in the eye to replace the natural crystalline lens. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Pseudophakos Intraocular Lens
The intraocular lenses listed below are covered prosthetic devices and are processed under the applicable procedure codes, subject to benefit coverage:
- Iris fixation lenses
- Irido-capsular fixation lenses
- Posterior chamber lenses
- Anterior chamber angle fixation lenses
The intraocular lenses listed below are not covered prosthetic devices, as their purpose is to avoid the need for glasses following cataract surgery. Corrective lenses provided solely for refractive error or to compensate for the imperfect curvature of the cornea (astigmatism) are not a standard benefit and are excluded from coverage.
- Presbyopia-correcting intraocular lens (e.g., CrystaLens, RESTOR, ReZoom)
- Astigmatism-correcting intraocular lens and Clear lens extraction intraocular lens
If a member chooses to have a presbyopia or astigmatism-correcting intraocular lens following cataract surgery, the lens itself will be denied as non-covered.
Any additional pre- and post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL will also be denied as non-covered.
Phakic intraocular lenses are not covered prosthetic devices, as their purpose is to avoid the need for glasses. They are not a standard benefit and are excluded from coverage.
Ocular Telescopic Prosthesis including removal of Crystalline Lens is considered experimental/investigational.
Clear lens extraction intraocular lens is not a covered prosthetic device, as the purpose is to avoid the need for glasses. They are not a standard benefit and are not covered.
Presbyopia and astigmatism-correcting IOLs are non-covered and will be denied.
Any additional pre- and post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL will also be denied as non-covered.
When the presbyopia-correcting or astigmatism-correcting intraocular lens is inserted solely for the correction of refractive errors or to compensate for the imperfect curvature of the cornea (i.e., not for cataract surgery), the lens, the surgical procedure, and all pre- and post-operative care will deny as non-covered and will entirely be the member’s financial responsibility.
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See Medical Policy Bulletin S-41 for further information on cataract extraction.
| Place of Service: Outpatient |
Intraocular Lens Insertion is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
