Noncovered Services with Cataract Surgery

Most items and services associated with routine cataract surgery are covered under Medicare’s national policy (NCD 10.1). This includes a comprehensive eye exam, biometry with IOL calculation and, when necessary, a B-scan for dense cataract. There are some things that are not covered and the beneficiary is financially responsible for payment.

The Medicare law (Social Security Act, Title XVIII) limits health care coverage. Medicare does not pay for everything, even care that beneficiaries or their doctors have good reason to think is necessary. Although Medicare beneficiaries may be disappointed, the fact is that Medicare does not cover routine eye care, specifically refractions, nor does it cover cosmetic surgery including most refractive procedures, such as refractive keratoplasty Services associated with presbyopia- or astigmatism-correcting IOLs are also noncovered.

This FAQ addresses the following:

  1. Does Medicare cover all items and services associated with cataract surgery?
  2. Why doesn’t Medicare cover everything related to cataract surgery?
  3. But Medicare does cover postcataract eyeglasses.  Please explain.
  4. When diagnostic tests are performed during the postoperative period, aren’t they bundled with the surgery?
  5. What other diagnostic tests might be noncovered?
  6. Some ophthalmologists offer pseudophakic monovision to patients.  Are there any noncovered charges for that?
  7. Are there any noncovered charges for evaluation and treatment of astigmatism at the time of cataract surgery?
  8. Are there any noncovered services associated with conventional IOLs within an ambulatory surgery center (ASC)?
  9. Some noncovered services are indispensable to the surgeon.  Does the patient get to choose whether to have them?
  10. Must a Medicare beneficiary sign an ABN before receiving any non-covered items or services?
  11. What is the benefit to the patient for noncovered services?

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