A cataract is an opacity or cloudiness in the crystalline lens of the eye, blocking the passage of light through the lens, sometimes resulting in blurred or impaired vision. A conventional intraocular lens (IOL) is a small, lightweight, clear disk that replaces the distance focusing power of the eye’s natural crystalline lens.

Presbyopia, a type of refractive error, is an age-associated progressive loss of the focusing power of the lens of the eye, resulting in difficulty seeing objects at near distance or "close up." Presbyopia occurs as the natural lens of the eye becomes thicker and less flexible with age. 

A conventional IOL means a small, lightweight, clear disk that replaces the distance focusing power of the eye's natural crystalline lens.  When a conventional IOL is inserted subsequent to removal of a cataract, eyeglasses or contact lenses are usually required to provide near or intermediate vision.

A presbyopia-correcting IOL (e.g., CrystaLens, RESTOR, ReZoom) is indicated for primary implantation in the capsular bag of the eye for the visual correction of aphakia (absence of the lens of the eye) and is also intended to provide near, intermediate, and distance vision without, in many patients, the need for eyeglasses or contact lenses. A single presbyopia-correcting IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia-correcting) and "reading" glasses or contact lenses.

Regular astigmatism is a visual condition where part of an image is blurred due to uneven corneal curvature.  A normal cornea has the same curvature at all axes, whereas the curvature of an astigmatic cornea differs in two primary axes, resulting in vision that is distorted at all distances.

An astigmatism-correcting IOL is indicated for primary implantation in the capsular bag of the eye for the visual correction of aphakia (absence of the lens of the eye) in patients with pre-existing astigmatism, and is intended to provide improved near, intermediate and distance vision.

Conventional Intraocular Lens

A conventional intraocular lens (IOL) is covered when implanted following cataract surgery.
 
Presbyopia-Correcting Intraocular Lens (V2632, V2788)

Medicare will cover one pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an IOL. However, Medicare does not cover the accommodative change in eyeglass or contact lens power that is required to compensate for the gradual loss of near vision as presbyopia progresses. Therefore, the presbyopia-correcting functionality of an IOL (V2788) is not covered. 

Any additional physician services required to monitor a patient receiving a presbyopia-correcting IOL are also not covered. For example, eye examinations performed to determine the refractive state of the eyes following insertion of a presbyopia-correcting IOL are non-covered.

The payment for a conventional IOL furnished in a physician’s office is not bundled with the procedure to insert the IOL following cataract surgery. The payment amounts for the IOL device and insertion procedure are two separate charges. A member may request insertion of a presbyopia-correcting IOL in place of a conventional IOL following cataract surgery. In this case, the presbyopia-correcting IOL device is considered partially covered. The member is responsible for payment of that portion of the physician’s charge for the presbyopia-correcting IOL that exceeds the physician’s charge for a conventional IOL following cataract surgery.

Physicians inserting an IOL or a presbyopia-correcting IOL in a physician's office setting may bill code V2632 for the IOL or the presbyopia-correcting IOL.  Payment will be made for code V2632.  When submitting claims for the presbyopia-correcting IOL, physicians may also bill code V2788 for the presbyopia-correcting function of the intraocular lens.  The additional functionality of this IOL is not eligible for payment.

Regardless of site-of-service for insertion of a presbyopia-correcting IOL, the member is responsible for payment of physician services attributable to the non-covered functionality of a presbyopia-correcting IOL inserted following cataract surgery. In determining the physician service charge, the physician may take into account the additional physician work and resources required for insertion, fitting, and vision acuity testing of the presbyopia-correcting IOL compared to insertion of a conventional IOL. The member is responsible for payment of the charges for physician services that exceeds the physician charge for insertion of a conventional IOL following cataract surgery.

Surgical fees for cataract extraction with lens insertion are to be paid under code 66982-66984, whichever is reported.

Codes 66985 and 66986 may be used to report the insertion or replacement of a presbyopia-correcting intraocular lens subsequent to cataract surgery.  66985 is for a secondary implant, not associated with concurrent cataract extraction and 66986 is for the exchange of the intraocular lens.

Astigmatism-Correcting Intraocular Lens (V2632, V2787)

There is no benefit category to allow payment for the surgical correction of cylindrical lenses of eyeglasses or contact lenses that may be required to compensate for the imperfect curvature of the cornea (astigmatism).  A network provider can bill the member for the denied services.

The astigmatism-correcting IOL is intended to provide what is otherwise achieved by two separate items:  An implantable conventional IOL (one that is not astigmatism-correcting) that is covered, and the surgical correction, eyeglasses, or contact lenses that are not covered.

Although astigmatism-correcting IOLs may serve the same function as eyeglasses or contact lenses furnished following removal of a cataract, astigmatism-correcting IOLs are neither eyeglasses nor contact lenses.

When the member requests insertion of an astigmatism-correcting IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the member is responsible for payment of facility charges for services and supplies attributable to the astigmatism-correcting functionality of the astigmatism-correcting IOL:

1. In determining the member’s liability, the physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing and monitoring of the astigmatism-correcting IOL that exceed the work and resources attributable to the insertion of a conventional IOL.
   
   
2. The physician may not charge for cataract extraction with insertion of an astigmatism-correcting IOL unless the member requests this service.
   
   
3. The physician may not require the member to request an astigmatism-correcting IOL as a condition of performing a cataract extraction with IOL insertion.

BENEFIT SUMMARY

NOTE:

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.

CMS Ruling No. 05-01, May 3, 2005

CMS Pub 100-4, Transmittal 636, CR 3927

CMS Pub 100-04, Transmittal 801, CR 4184

CMS Pub 100-04, Transmittal 1228, CR 5527

CMS Pub 100-03, Section 80.12

Medlearn Matters Number: MM 3927