Description

An intraocular lens (IOL) implant is a small, clear, plastic lens that is used to replace the native (natural) lens of the eye when it has been surgically removed (most often during cataract surgery). The IOL becomes a permanent part of the eye, not requiring any care and cannot be seen or felt. An IOL is used to improve vision after the native lens is removed by helping to focus light directly onto the retina.

IOLs can be classified as standard, premium or refractive and can be further identified according to type – monofocal, multifocal, trifocal, accommodating, extended range, light adjustable, toric and phakic. Most IOLs are made using special materials (chromophores) that absorb ultraviolet light. Some IOLs may be a combination of more than one type (eg, light absorbing monofocal, trifocal toric) and most IOLs are available in multiple models (see Appendix A for examples).

Standard IOLs

• Monofocal IOLs have a fixed focal length and provide clear vision at a single distance (near, intermediate or far) only. Following monofocal lens placement, glasses may be required to assist with near or distance vision.

Premium IOLs

Premium IOLs are designed to correct refractive errors (astigmatism, hyperopia [farsightedness], myopia [nearsightedness] and presbyopia [age-related lens rigidity which limits the ability to focus for near vision]). The intent of premium lenses is to eliminate the need for reading glasses or contact lenses after surgery. (Refer to Coverage Limitations section)

• Accommodating IOLs are intended to mimic the accommodation of the natural lens, focusing both distant and near images onto the retina.
• Extended Range IOLs purport to provide an extended depth of focus which improves intermediate and near visual acuity, while maintaining comparable distance visual acuity to other types of IOLs.
• Light Adjustable IOLs are made of photosensitive material, that incrementally changes the implanted lens in response to ultraviolet light treatments. As the IOL shape changes so does the power, adjusting for astigmatism, farsightedness and/or nearsightedness.
• Multifocal IOLs focus both distant and near images onto the retina.
• Toric IOLs correct astigmatism.
• Trifocal IOLs allow for near, intermediate and distance vision with some models also correcting astigmatism.

Refractive IOLs

Refractive IOLs are solely intended to correct refractive errors and are placed without removing the natural lens. (Refer to Coverage Limitations section)

Phakic IOLs

Phakic IOLs are used to achieve refractive correction when the native lens is not removed, similar to the effect of LASIK or laser eye surgery.

Coverage Determination

Humana members may be eligible under the Plan for standard* fixed (nonaccommodating) monofocal intraocular lens implants for the following indications:

• Aphakia (including that which results from congenital cataract extraction); OR
• Cataract (including congenital and traumatic); OR
• Lens subluxation or displacement

Humana members may be eligible under the Plan for intraocular lens implant revision or removal with replacement using standard* fixed (nonaccommodating) monofocal lenses.

Humana members who choose premium IOLs (accommodating, extended range, light adjustable, multifocal, toric or trifocal) for initial implantation or replacement are responsible for costs above the standard allowable rate. *Standard IOLs meet the basic functional needs of an individual’s physical condition. Since the intent of the multifocal and accommodating IOLs is to preclude the need for reading glasses or contact lenses post-surgery, those types of IOLs are considered not medically necessary. (Refer to Coverage Limitations section)

Note: The criteria for IOL implants are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

Coverage Limitations

Humana members may NOT be eligible under the Plan for IOLs for any indications other than those listed above or for the following types of premium or refractive lenses including, but may not be limited to:

• Accommodating toric; OR
• Extended range; OR
• Extended range toric; OR
• Light adjustable; OR
• Monofocal accommodating; OR
• Monofocal toric; OR
• Multifocal; OR
• Multifocal toric; OR
• Phakic; OR
• Trifocal; OR
• Trifocal toric

These are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition. The plan allows for reimbursement for standard* fixed (monofocal nonaccommodating) IOLs. Humana members who meet criteria for IOL placement and opt to use premium IOLs, (accommodating, extended range, light adjustable, multifocal, toric or trifocal) are responsible for any cost above the standard allowable rate.

Note: Refractive eye surgeries (eg, LASIK, laser eye surgery, etc.) are generally excluded by certificate therefore, any IOL implant done for refractive purposes or in conjunction with this type of procedure would not be covered if the surgery itself is not a covered benefit.

The use of laser assistance in conjunction with cataract removal surgery is considered integral to the primary procedure and not separately reimbursable.

Additional information about cataracts, eye conditions and lens implants may be found from the following websites:

Background

• American Academy of Ophthalmology
• National Eye Institute
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific