Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 02/03/2010	Title: Intraocular Lenses (IOL)
Revision Date: 08/01/2020	Document: BI254:00
CPT Code(s): Q1003, Q1004, Q1005, V2630, V2787, V2788, 0616T, 0617T, 0618T
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Cataract surgery and insertion of monofocal intra-ocular lenses (IOL) is covered by QualChoice. 2) Other lenses designed to avoid the need for glasses after surgery and used in this surgery are not covered. 3) Insertion of iris prosthesis requires prior authorization.
Medical Statement
Medical Policy Statement: 1) Standard fixed monofocal posterior chamber intraocular lenses (IOL) are considered medically necessary for use during cataract surgery 2) Accommodating posterior chamber IOLs (e.g., Crystalens, Eyeonics Inc., Aliso Viejo, CA), apodized diffractive optic IOLs (e.g., AcrySof ReSTOR, Alcon, Inc., Fort Worth, TX), ultraviolet absorbing lenses (e.g., AcrySof Natural blue-light filtering IOL, Alcon, Inc., Fort Worth, TX, and C-flex IOL model 570C, Rayner Surgical Inc., Los Angeles, CA), multifocal posterior chamber IOLs, and other new technology lenses (e.g., the Sofport LI61AO aberration-neutral IOL, Bausch & Lomb, San Dimas, CA) are considered noncovered deluxe items. 3) Insertion of iris prosthesis requires prior authorization. It is considered medically necessary for complete absence of iris due to congenital condition or due to eye damage. Codes Used In This BI: Q1003 Ntiol category 3 (code deleted 04/01/2011) Q1004 Ntiol category 4 Q1005 Ntiol category 5 V2630 Anter chamber intraocul lens V2787 Astigmatism-correct function V2788 Presbyopia-correct function 0616T Insertion of iris prosthesis without removal/insertion of intraocular lens 0617T Insertion of iris prosthesis with removal/insertion of intraocular lens 0618T Insertion of iris prosthesis with intraocular lens exchange
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.