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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 

The rules say that lens extraction is considered medically necessary and therefore covered by Medicare when 
one (or more) of the following conditions or circumstances are documented in the medical record: 

1. Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual 
function not correctable with a tolerable change in glasses or contact lenses resulting in the patient's 
inability to function satisfactorily while performing Activities of Daily Life including, but not limited to 
reading, viewing television, driving, or meeting vocational or recreational needs. 
2. Concomitant intraocular disease (e.g., diabetic retinopathy or intraocular tumor) requiring monitoring or 
treatment that is prevented by the presence of cataract. 
3. Lens-induced disease threatening vision or ocular health (including, but not limited to, phacomorphic or 
phacolytic glaucoma). 
4. High probability of accelerating cataract development as a result of a concomitant or subsequent 
procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments 
such as external beam irradiation. 
5. Cataract interfering with the performance of vitreoretinal surgery. 
6. Intolerable anisometropia or aniseikonia uncorrectable with glasses or contact lenses that exists as a 
result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity. 
 
 The following documentation must be present in the medical chart: 
 
For Visually-Symptomatic Cataract: 

a. A statement indicating that specific symptomatic (i.e., causing the patient to seek medical attention) 
impairment of visual function resulting in the patient's inability to function satisfactorily while 
performing Activities of Daily Life. Such activities would typically include, but are not limited to, 
reading, viewing television, driving, or meeting vocational or recreational expectations. The patient's 
own words should be included in the statement where possible. 
b. A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) 
as determined by a careful refraction under standard testing conditions as appropriate must be recorded 
to establish the inability to correct the patient's visual function with a tolerable change to glasses or 
contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patient's current 
prescription will satisfy this requirement. The refraction may be performed by the surgeon or by 
suitably trained staff in the surgeon's practice as permitted by law. 
c. A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when 
cataract is the primary cause of visual compromise. 
d. An attestation supported by documented symptoms and physical findings in the medical record 
indicating that the patient's impairment of visual function is believed not to be correctable with a 
tolerable change in glasses or contact lenses. 
e. When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., 
macular degeneration or diabetic retinopathy), the attestation should indicate that cataract is believed to 
be significantly contributing to the patient's visual impairment. 
f. A statement that the patient desires surgical correction, that the risks, benefits, and alternatives have 
been explained, and that a reasonable expectation exists that lens surgery will significantly improve 
both the visual and functional status of the patient 

For Other types of Cataract: 

a. A statement indicating that the appropriate medical condition or circumstance exists and the specific 
reason for surgical intervention (e.g., "Cataract surgery is being performed to establish clear media for 
the treatment [or monitoring] of diabetic retinopathy). 
b. A statement that the patient desires surgical correction, that the risks, benefits, and alternatives have 
been explained, and that the patient understands that the surgery is being done to address the medical 
condition or circumstance. If vision is specifically not expected to improve, the statement should 
include the patient's understanding of that fact.  

For All types of Cataract: 
 
a. An appropriate preoperative ophthalmologic evaluation, which generally includes a comprehensive 
ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain 
examination components may be appropriately excluded based on the specific condition and/or urgency 
of surgical intervention. 
b. Results and interpretation of specialized ophthalmic studies done for medically necessary reasons 
unique to the patient's situation. 
c. Results and interpretation of specialized ophthalmic studies that are not expected to be routinely 
performed for routine cataract surgery with clear statements of the reasons they are needed to 
establish or exclude medical necessity. 

You can find this information in the Local Coverage Determination (LCD): Cataract Surgery in Adults 
(L34203).  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.