MA PPO

Reimbursement for an Intraocular Lens
MA11.043a

Policy


Conventional intraocular lenses (IOLs) inserted following removal of a cataract are covered and eligible for reimbursement by the Company.

 

Presbyopia-correcting and astigmatism-correcting IOLs, which includes New Technology Intraocular lens, are not covered by the Company because they are items or services not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

 

When a member chooses to have a presbyopia-correcting IOL or an astigmatism-correcting IOL inserted following cataract removal, the member is financially responsible for the portion of charges associated with for the presbyopia-correcting or astigmatism-correcting IOL that exceed the charges for the conventional IOL.

 

​Providers must document on the Company-approved form that any individual who consents to the presbyopia- or astigmatism-correcting IOL has been informed that this device is not covered and has agreed to pay the portion of the charge for the presbyopia- or astigmatism-correcting IOL that exceeds the charge for the conventional IOL.

 

REQUIRED DOCUMENTATION

 

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

 

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.​



Guidelines


This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

 

BENEFIT APPLICATION


Subject to the terms and conditions of the applicable Evidence of Coverage, conventional intraocular lenses IOLs inserted following removal of a cataract are covered under the medical benefits of the Company's Medicare Advantage products.

 

Subject to the applicable Evidence of Coverage Presbyopia-correcting, astigmatism-correcting, and new technology IOLs are not eligible for payment under the medical benefits of the Company's Medicare Advantage products because the service is considered not covered.

 

FINANCIAL RESPONSIBILITY

 

For individuals receiving a presbyopia- or astigmatism-correcting IOL, the member is not responsible for the cost of the conventional IOL or the surgical procedure for insertion of the lens. However, the member is financially responsible for the portion of the charge for the presbyopia-correcting or astigmatism-correcting IOL that exceeds the charge for a conventional IOL. Member reimbursement requires the submission of a paid receipt or invoice, along with the specific claim form used to process this type of service. This claim form can be obtained by contacting Member Services or through the Company website.

 

BILLING GUIDELINES

 

For individuals who receive a conventional IOL, professional providers should report the appropriate Healthcare Common Procedural Coding System (HCPCS) code for the conventional IOL: V2630, V2631, or V2632.

 

For individuals who receive the presbyopia-correcting IOL, professional providers should report V2788. For individuals who receive the astigmatism-correcting IOL, providers should report V2787. For individuals who receive an NTIOL, outpatient facilities should report HCPCS code C1780.

 

Professional providers and/or outpatient facilities should report the appropriate Healthcare Common Procedural Coding System code that represents the insertion of conventional, presbyopia-correcting, astigmatism-correct or new technology intraocular lens.



Description


When an individual has a cataract removed, a conventional intraocular lens (IOL) may be used to replace the eye's natural crystalline lens. The IOL is a small, lightweight clear disk.

 

A presbyopia-correcting or astigmatism-correcting IOL, which includes a new technology IOL, is an optional replacement for the natural lens of the eye. In most cases, presbyopia-correcting and/or astigmatism-correcting IOLs eliminate the need for eyeglasses or contact lenses. A single presbyopia-correcting or astigmatism-correcting IOL can provide what would otherwise be achieved with both a conventional implantable IOL and corrective eyeglasses or contact lenses.

 

Presbyopia is a type of refractive error that results in progressive loss of the focusing power of the lens of the eye. As the natural lens becomes thicker and less flexible with age, individuals with presbyopia may experience difficulty seeing objects at a distance, up close, or both.

 

Astigmatism is an optical defect in which refractive power is not uniform in all directions. Light rays entering the eye are bent unequally by different meridians, preventing formation of a sharp image focus on the retina.



References


Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. CMS Manual System. Pub 100-04: Medicare Claims Processing. Transmittal 1228. Instructions for implementation of CMS 1536-R; Astigmatism-correcting intraocular lens (A-C IOLs). [CMS Web site]. 04/27/2007. Available at: http://www.cms.hhs.gov/Transmittals/Downloads/R1228CP.pdf. Accessed May 11, 2018.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. CMS Rulings. Ruling No. 05-01. [CMS Web site]. 05/03/2005. Available at: http://www.cms.hhs.gov/Rulings/downloads/CMSR0501.pdf. Accessed May 11, 2018.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. MLN Fact Sheet. Medicare Vision Services. April 2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/VisionServices_FactSheet_ICN907165.pdf.   Accessed March 26, 2020

 

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. New Technology Intraocular Lens (NTIOLS). 02/11/2020. Available at:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/NTIOLs.  Accessed March 26, 2020.​



Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)


H52.201 Unspecified astigmatism, right eye

H52.202 Unspecified astigmatism, left eye

H52.203 Unspecified astigmatism, bilateral

H52.209 Unspecified astigmatism, unspecified eye

H52.211 Irregular astigmatism, right eye

H52.212 Irregular astigmatism, left eye

H52.213 Irregular astigmatism, bilateral

H52.219 Irregular astigmatism, unspecified eye

H52.221 Regular astigmatism, right eye

H52.222 Regular astigmatism, left eye

H52.223 Regular astigmatism, bilateral

H52.229 Regular astigmatism, unspecified eye

H52.4 Presbyopia



HCPCS Level II Code Number(s)

V2630

Anterior chamber intraocular lens
V2631Iris supported intraocular lens
V2632Posterior chamber intraocular lens


  BENEFIT EXLCUSION

C1780Lens, intraocular (new technology)
S0596Phakic intraocular lens for correction of refractive error
V2787Astigmatism correcting function of intraocular lens
V2788Presbyopia correcting function of intraocular lens​



Revenue Code Number(s)

0276 Medical/Surgical Supplies and Devices - Intraocular Lens



Coding and Billing Requirements


Policy History

1/18/2021
1/18/2021
MA11.043
Medical Policy Bulletin
Medicare Advantage
No