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Decision: unknown

 
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. 
 
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 (see Documentation 
Requirements): 
1. Cataract causing symptomatic 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 requiring monitoring or treatment that is prevented by the presence of 
cataract. 
3. Lens-induced disease threatening vision or ocular health. 
4. High probability of accelerating cataract development as a result of a concomitant or subsequent 
procedure 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. 
 
Any circumstances not listed may be considered based on the standard of care and other factors related to 
medical necessity at redetermination. Surgery is not deemed to be medically necessary purely on the basis of 
lens opacity in the absence of symptoms. You can find these rules in Local Coverage Determination (LCD) 
Cataract Surgery in Adults (L37027). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for 
the difference in cost between the P-C IOL and a conventional IOL. The presbyopia-correcting feature of an 
IOL is not covered by Medicare. You can find this rule in the CMS Ruling, Number 05-01, Presbyopia-
Correcting IOLs, May 3, 2005. 
 
The rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible 
for the difference in cost between the A-C IOL and a conventional IOL. The astigmatism-correcting feature of 
an IOL is not covered by Medicare. You can find this rule in the CMS Ruling, No. CMS-1536-R, 
Astigmatism-Correcting IOLs, January 22, 2007. 
 
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.