The intraocular lenses listed below are eligible prosthetic devices and are processed under the applicable procedure codes, subject to benefit coverage:

1. Iris fixation lenses (V2631)
2. Irido-capsular fixation lenses (L8699)
3. Posterior chamber lenses (V2632)
4. Anterior chamber angle fixation lenses (V2630)

The intraocular lenses listed below are not eligible 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 - V2630, V2631, or V2632 and V2788)
Astigmatism-correcting intraocular lens - V2630, V2631, or V2632 and V2787

If a member chooses to have a presbyopia-correcting or astigmatism-correcting intraocular lens  following cataract surgery (procedure codes 66982-66984), the lens itself will be denied as non-covered (see NOTE below). However, the surgical procedure will be eligible for payment. 

Physicians inserting a presbyopia or astigmatism-correcting IOL in a physician's office setting may bill the appropriate code V2630, V2631, or V2632 for the presbyopia-correcting or astigmatism-correcting IOL, along with code V2788 for the presbyopia-correcting function of the intraocular lens or V2787 for the astigmatism-correcting function of the intraocular lens.  Since presbyopia and astigmatism-correcting IOLs are non-covered, both codes will be denied (see NOTE below).

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 (see NOTE below).

NOTE:

Prior to surgery, the provider must obtain a signed agreement from the patient. This agreement must specifically inform the patient that he/she is responsible for the entire cost of the presbyopia-correcting or astigmatism-correcting intraocular lens and any additional pre- and post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL. This documentation must be retained in the patient’s medical record and be available upon request. If a participating, preferred, or network provider fails to get a signed agreement from the patient prior to surgery, the provider is responsible for the cost of the lens and any additional pre- and post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL.

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. A participating, preferred, or network provider can bill the member for the non-covered services.

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

Coverage for prosthetics is determined according to individual or group customer benefits.

Description

An intraocular lens (pseudophakos) is a hard type of artificial lens which is surgically implanted in the eye to replace the natural crystalline lens.

Presbyopia is the natural age-related loss of capacity to focus from far to near and back again.  A presbyopia-correcting intraocular lens is an artificial lens used to correct the visual impairment of aphakia after cataract surgery and is intended to restore a patient’s ability to see objects far away and near, in most cases without the use of contacts or eye glasses. A presbyopia-correcting intraocular lens can also be used solely to correct refractive errors.

Astigmatism is a common condition that can make your vision distorted or blurred.  The distortion is because the eye's cornea or lens has an irregular shape, usually slightly oval instead of the preferred round shape.  An astigmatism-correcting intraocular lens is an artificial lens that restores focus to the eye by correcting pre-existing astigmatism.

See Medical Policy Bulletin S-14 for further information on cataract extraction.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

FDA approved first accommodative IOL, Ophthalmology Times, January 1, 2004

Moving Forward with the Crystalens, Review of Ophthalmology, January 2004

The Crystalens Accommodative IOL, Supplement to Cataract & Refractive Surgery Today, March 2004

New Hope for Presbyopes, EyeNet, American Academy of Ophthalmology, May 2004

CMS Pub 100-04, Transmittal 1228, CR 5527