Cataract Surgery denials in California external review

What the reviewers wrote

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.

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has shown some issues with medication compliance. The provider has recommended intervention with the iStent procedure. On review of the current peer-reviewed medical literature, there is data that the iStent has been found to be a safe and effective treatment modality for this patient’s ocular hypertension with improvement in intraocular pressure (IOP).

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 describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cataract Surgery, then check the rights and deadlines that apply to your plan.