In those rare cases when the insertion of a premium intraocular lens (IOL) does not produce the desired vision along with a happy patient, the surgeon is motivated to find a solution. When this happens, who is responsible for the cost of addressing the issue—the patient or a third-party payor?
Solutions such as an IOL exchange require significant physician and ambu- latory surgery center (ASC) resources. Some surgeons and ASCs presume that insurance covers any complication requiring further intervention. Others believe that the upgraded fee includes all follow-up procedures.
The answer lies somewhere in between. Coverage depends on the nature of the problem, the medical necessity of the intervention, and the specific policies of the payor involved. To illustrate, we developed three case studies.
CASE 1: IOL Repositioning
Scenario
A patient underwent cataract surgery with implantation of a toric IOL. At the 1-day postoperative visit, the patient’s uncorrected vision was 20/30. At the 1-week follow-up, vision remained unchanged at 20/30. A refraction of -0.25 +0.50 x 155° improved the vision to 20/25+.
However, the patient demanded spectacle independence. To address the residual refractive error, the surgeon elected to return the patient to the OR to rotate the IOL to the appropriate axis.
Coverage
In this case, the procedure did not satisfy the medical necessity criteria for third-party coverage. Although the patient returned to the OR, the visual acuity was borderline, with a best-
corrected vision of 20/25—achievable with a tolerable spectacle prescription. The patient’s demand to eliminate any need for corrective lenses influenced the surgeon’s decision to rotate the IOL. Medicare would likely determine that postoperative glasses represent an adequate solution and deny coverage for the IOL rotation. This appears to represent a “refractive” IOL reposition that does not satisfy medical necessity.
CASE 2: IOL Exchange
Scenario
Six weeks after cataract surgery with implantation of a presbyopia-correcting IOL (PC-IOL), the patient remained dissatisfied with their uncorrected vision. The visual complaints were vague and difficult to localize, but persisted despite all non-invasive treatments, including prescription glasses. The patient continued to report significant visual disturbances, including difficulty driving.
After a thorough evaluation and multiple refractions, the surgeon diagnosed the patient with intolerable pseudophakic dysphotopsia and proceeded with an IOL exchange.
Coverage
The IOL exchange is medically necessary, as the surgeon exhausted all non-surgical treatment options without resolving the patient’s symptoms. Thus, coverage for the intervention exists.
CASE 3: YAG Capsulotomy
Scenario
A patient with a history of LASIK presented with visually significant cataracts and a desire for spectacle independence at both distance and near. The surgeon implanted a PC-IOL. At the 3-week postoperative visit, the patient remained unhappy despite an uncorrected distance visual acuity of 20/25 in the operated eye. No manifest refraction was performed to assess for a residual refractive error. The surgeon recommended going ahead with a YAG capsulotomy.
Coverage
First, the surgeon did not assess best- corrected visual acuity prior to the YAG capsulotomy. Second, the YAG was performed during the global postoperative period. In this context, it appears the surgeon performed the YAG primarily to address a refractive concern rather than significant posterior capsular opacification. Thus, Medicare and/or third-party payors would determine that the procedure does not meet medical necessity requirements and would not cover the cost.
Documentation Matters
Patients who choose and pay for premium IOLs have certain outcome expectations. However, when the problem is a residual refractive error that interferes with spectacle independence, Medicare and other third-party payors will not cover treatment such as an IOL exchange, early YAG, or other invasive procedures.
Medicare provides a spectacle benefit to treat residual or uncorrected refractive errors after cataract surgery. So, if a tolerable change in spectacles fixes the problem, coverage is unlikely. In the end, the merits of each case will depend on the documentation in the chart. OM