Cataracts: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The spouse of an enrollee has requested authorization and coverage for immediate cataract surgery.The American Academy of Ophthalmology (AAO) has issued interim guidelines on resuming elective ophthalmic care during the COVID-19 pandemic. The AAO states that cataract surgery is considered semi-urgent, not elective, when the affected person cannot drive, work or see to take their medications properly, or has an increased risk of falling, phacomorphic glaucoma or intolerable anisometropia. The AAO states that such cases warrant surgery within days to weeks. In this case, because the patient has a history of dementia and decreased mobility, the typical considerations of encumbered working or risk of falling are not applicable.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the iStent trabecular micro-bypass procedure for treatment of the enrollee’s primary open angle glaucoma. Findings: The physician reviewers found that The iStent is a minimally invasive device that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glaucoma in patients who are undergoing cataract surgery. The iStent device has been found to be effective in patients with mild-to-moderate glaucoma who are undergoing cataract surgery at the same time. The overall effect of the iStent on the intraocular pressure is modest and its use is not appropriate for patients who have advanced glaucoma and an intraocular pressure that is uncontrolled with medication.

Where the denial was upheld

An enrollee has requested reimbursement for premium intraocular lenses. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s macular degeneration and cataracts. A review of the record indicates that the enrollee had right eye cataract surgery performed on 04/10/2018, and left eye cataract surgery performed on 05/08/2018. On these dates of service, the enrollee also had premium intraocular lenses implanted. The enrollee has stated that premium intraocular lenses were necessary to treat her macular degeneration.The submitted documentation does not support that the services at issue were medically necessary. Records of the patient’s history and physical reflect that the patient had macular degeneration and was found to have decreased visual acuity and cataracts on examination.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of presbyopia correcting intraocular lenses (V2788) after cataract surgery and the use of a laser (ZCAT) to assist with performing the cataract surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Findings: Femtolaser assisted cataract surgery (FLACS) and presbyopia correcting intraocular lenses are not considered a medical necessity in standard cataract surgery. Femtolaser has been utilized in different aspects of cataract surgery such as creation of incisions, arucate keratotomies, and anterior capsulorrhexis and nuclear fragmentation. Studies have indicated that FLACS does not carry additional risk compared to non-FLACS small incision phacoemulsification cataract surgery.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for cataracts was denied, the published record says the denial is worth fighting.