Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens. We decided that the Plan does not have to pre-approve an astigmatism correcting function of intraocular lens and an unlisted procedure.
You asked the Plan to pre-approve a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens. You say that the enrollee needs this because he had this surgery in his right eye previously. The Plan says that these procedures are not medically necessary.
We decided that the Plan has to pre-approve a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens.
The Plan follows Medicare rules. Medicare rules say that lens extraction is considered medically necessary and therefore covered by Medicare when one (or more) of the above listed circumstances exist. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens. Our reviewer says that the patient underwent cataract surgery in the right eye and now has noticed improvement in vision in that eye. His complaints of difficulty focusing and driving indicate that he may be experiencing anisometropia given the significant different in uncorrected VA between the eyes. Based on the patient's complaints, likely anisometropia from unilateral cataract surgery, and the exam findings of the left eye cataract, it is likely that the cataract is visually significant. Therefore, it is indicated to proceed with cataract surgery (66984) with posterior chamber lens (V2632). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens have been met. Therefore, we decided that the Plan has to pre-approve a cataract surgery with the insertion of a lens and a posterior chamber intraocular lens.
We also decided that the Plan does not have to pre-approve an astigmatism correcting function of intraocular lens and an unlisted procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an astigmatism correcting function of intraocular lens and an unlisted procedure. Our physician reviewer found there is no medical necessity for astigmatism correcting function of intraocular lens (V2787) and unlisted procedure (99244). Toric lens are an added benefit for patients who prefer to have their astigmatism corrected at the time of surgery. The standard monofocal lens does not correct for astigmatism, however, postoperatively it can be corrected by glasses or contact lenses. It is unclear what the unlisted procedure is and therefore cannot be determined to be medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an astigmatism correcting function of intraocular lens and an unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an astigmatism correcting function of intraocular lens and an unlisted procedure.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.