Medicare Reimbursement for the TECNIS Eyhance IOLs (J&J Surgical)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR THE TECNIS EYHANCE™ IOLS

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Q For Medicare reimbursement, how are TECNIS Eyhance™ IOLs classified?

A Medicare classifies the TECNIS Eyhance™ IOL as a conventional IOL, while the TECNIS Eyhance™ Toric II IOL is an astigmatism-correcting IOL.

Q Is the Medicare beneficiary financially responsible for any portion of these IOLs?

A Beneficiaries, when properly informed and consented, are financially responsible for a portion of the cost of an astigmatism-correcting IOL as a noncovered service. Beneficiaries are only responsible for the applicable deductible and copayment for a conventional IOL during covered cataract surgery.

Q Prior to implantation of these IOLs, what tests are indicated and covered?

A Under Medicare’s national coverage determination policy §10.1, biometry to determine IOL power is covered and, for patients with dense cataract, medically justified B-scan is covered. Medicare’s national coverage determination policy §80.8 provides coverage of endothelial cell photography prior to cataract surgery under restricted criteria for comorbid conditions.

Q Prior to implantation of these IOLs, what tests are not covered?

A Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented. For example, refraction, aberrometry for higher order optical aberrations, corneal topography for regular astigmatism, corneal pachymetry to plan corneal relaxing incisions, and screening with SCODI for pathology of the macula are not covered.

Q How are charges determined for noncovered tests?

A The surgeon’s usual and customary charges for the noncovered tests are summed to arrive at a total fee for pre-operative testing. Since both eyes are evaluated prior to the first cataract operation, a single charge is made. Alternately, the total fee can be divided in two equal parts – one for the first eye and one for the second.

Q What guidance did CMS, AAO, and ASCRS provide for the use of a femtosecond laser during cataract surgery?

A Since the end of 2010, some U.S. surgeons have used a femtosecond laser in refractive cataract surgery. CMS guidance on laser cataract surgery issued in November, 2012, states, “Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is performed using conventional surgical techniques or a bladeless, computer controlled laser. Under either method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens. If the bladeless, computer controlled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only charges for those non-covered services specified above may be charged to the beneficiary. These charges could possibly include charges for additional services, such as imaging, necessary to implant a PC-IOL or an AC-IOL but that are not performed when a conventional IOL is implanted. Performance of such additional services by a physician on a limited and non-routine basis in conventional IOL cataract surgery would not disqualify such services as noncovered services. This guidance does not apply to the use of technology for refractive keratoplasty.” ¹So, the use of the femtosecond laser, such as Catalys® Precision Laser System, to make alignment marks in the cornea to orient the TECNIS Eyhance™ Toric II IOL is an example of a noncovered service according to the CMS guidance.

Q What guidance did CMS, provide for the use of a femtosecond laser for keratoplasty?

A The longstanding national coverage determination policy for refractive keratoplasty (§80.7) states that Medicare statute §1862(a)(7) excludes coverage for keratoplasty for the purpose of refractive error compensation. Consequently, limbal or corneal relaxing incision performed with a femtosecond laser to correct clinically significant, pre-existing, regular astigmatism are the financial responsibility of the beneficiary. This policy applies for any cataract surgery without regard to the type of IOL that is implanted.

Q What documentation informs a beneficiary of financial responsibility for noncovered items and services?

A If coverage is unlikely or uncertain, explain to the patient why the item or service is necessary and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

¹ Centers for Medicare and Medicaid Services. Laser- Assisted Cataract Surgery and CMS Rulings 05-01 and 1536-4. November 16, 2012. Link here.

Provided Courtesy of Johnson & Johnson Surgical Vision, Inc.

Last updated June 16, 2021

The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

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