Medical Policy
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
Limits
Intentially left empty
Reference
Intentially left empty
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.