Payment For Presbyopia-Correcting Intraocular Lens (P-C IOL) and Astigmatism-Correcting Intraocular Lens (A-C IOLs)

Payment For Presbyopia-Correcting Intraocular Lens (P-C IOL) and Astigmatism-Correcting Intraocular Lens (A-C IOLs)

Medicare will allow beneficiaries to pay additional charges associated with insertion of a P-C IOL or A-C IOL following the extraction of a cataract:
• There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a P-C IOL or A-C IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.
• There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a P-C IOL or A-C IOL following removal of a cataract that exceeds the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.

When a beneficiary requests insertion of a P-C IOL or A-C IOL instead of a conventional IOL following removal of a cataract:
• Prior to the procedure to remove a cataract and insert a P-C IOL or A-C IOL, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment or other subsequent treatments related to the P-C or A-C functionality of the IOL.
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The P-C or A-C functionality of a IOL does not fall into a Medicare benefit category, and, therefore, is not covered. Therefore, the facility and physician are not required to provide an Advanced Beneficiary Notice to beneficiaries who request a P-C or A-C IOL.
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Although not required, NHIC strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to clearly identify the non-payable aspects of a P-C or A-C IOL insertion.
When a beneficiary requests insertion of a P-C or A-C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility and physician charges for services and supplies attributable to the P-C or A-C functionality of the IOL:
• In determining the beneficiary's liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C or A-C IOL that exceed the work and resources attributable to insertion of a conventional IOL.