Medicare patients can seek presbyopia-correcting IOLs

Washington, DC-Medicare patients may now choose to pay extra to correct presbyopia with an IOL after cataract surgery under a new ruling by the Centers for Medicare & Medicaid Services (CMS), opening a vast, untapped market for IOL manufacturers and cataract surgeons.

The May 3 decision allows patients to pay the difference between the cost of a traditional, monofocal IOL and its associated fees and that of an IOL that corrects for presbyopia.

The ruling specifies that a presbyopia-correcting IOL is not medically necessary and therefore is not covered (See "CMS issues ruling on IOLs for presbyopia,"). However, it opens the door to those who can afford the additional expense-estimates range up to $4,500 per eye-and possibly avoid wearing the Medicare-covered reading glasses associated with presbyopia.

However, the American Academy of Ophthalmology's (AAO) medical director of health policy is urging surgeons to be cautious, and a national group that advocates for a universal health insurance program is critical of it.

"I think it's a big deal for everybody," says Russ Trenary, AMO's corporate vice president and chief marketing officer. "This opens up fantastic opportunities."

Last year, Medicare-which provides coverage for all Americans over age 65- paid for the insertion of 1,765,000 traditional IOLs following cataract surgery, according to AAO's William L. Rich III, MD.

Health-maintenance organizations and traditional insurance only covered 700,000 eyes, he said.

J. Andy Corley, chairman and chief executive officer of eyeonics, said his company began lobbying for this change 5 years ago, believing patients should be able to choose to pay for the new lenses. Corley said he took it on as a solo mission because it seemed "so radical."

"Our position from day 1 was, we don't want the government or the taxpayer to pay another penny, we just want (beneficiaries) to have a choice," Corley said. "Medicare's position was, 'we're not going to pay for it and you can't have it.' We felt that that was an indefensible position, and if we could just get our message to the right people, we felt like we'd have a chance of winning."

Eventually Corley was joined in his efforts by AMO and Alcon, and, when he gained the support of his congressman, Rep. Christopher Cox (R-CA), officials in Washington, DC, started to listen.

"It was a classic case of Medicare policy not being able to keep up with changes in technology," Corley said.

Under the ruling, Medicare will continue to pay for the extraction of the cataract, and part of the cost to insert a presbyopia-correcting IOL. The beneficiary is responsible for paying for that portion of the charge that exceeds the facility charge for a conventional IOL, as well as any physician charges associated with the fitting and visual acuity testing of the new IOL that exceed that of a conventional type.

Although the presbyopia-correcting IOLs eliminate the need for reading glasses for many patients (the percentages vary from 26% to 80%, depending on the type), patients who choose to have an implant of this type do not lose their Medicare coverage for spectacles following cataract surgery.