| Highmark Commercial Medical Policy - Pennsylvania |
| 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:
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.
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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