Cataracts are a clouding of the natural lens in the eye that affects vision. As cataracts progress, they can cause blurry vision, sensitivity to light and glare, poor night vision, seeing “halos” around lights, double vision, and fading colors. Cataracts typically develop slowly over time as a part of the natural aging process, but can also occur due to eye injuries, medications, medical conditions, or as a congenital condition.
Cataract surgery is a procedure to remove the clouded natural lens and replace it with a clear artificial lens implant to restore vision. During cataract surgery, the surgeon makes a tiny incision in the eye and uses an ultrasound device to break up the cloudy lens, then suctions out the fragments. The artificial lens is then placed in the empty lens capsule. Cataract surgery is one of the most common and successful surgeries performed today, with over 3 million procedures done annually in the U.S. The surgery is generally safe and effective at improving vision impaired by cataracts.
Sources:
https://www.mayoclinic.org/tests-procedures/cataract-surgery/about/pac-20384765
Common Reasons for Denying Coverage
There are several common reasons why insurance companies may deny coverage for cataract surgery, including if it’s considered a pre-existing condition, an experimental procedure, or not medically necessary.
Pre-existing conditions refer to any health issues a patient already had before enrolling in an insurance plan. Most insurance policies will not cover treatment for pre-existing conditions for a period of time after enrolling, often 6-12 months. If someone develops cataracts before getting insurance, the insurer may claim it is pre-existing and deny coverage.
Insurers also commonly deny experimental or investigational procedures that have not been proven safe and effective. While cataract surgery itself is a standard procedure, there may be new devices or techniques a surgeon wants to use that the insurer considers experimental and will not cover.
One of the most frequent reasons for denial is the insurer claiming the surgery is not “medically necessary.” Most insurance policies only cover care that is a medical necessity, not elective. So even though a patient’s ophthalmologist recommends cataract surgery, the insurer may review the records and decide the condition is not severe enough yet to require surgery (1).
When Denials May Be Justified
In some cases, insurance companies may be justified in denying coverage for cataract surgery. This includes when the cataract is still mild and does not significantly impair vision. Medicare’s national coverage policy states that cataract surgery cannot be covered if the beneficiary’s vision is correctable to 20/40 or better in the affected eye using glasses or contact lenses [1]. Private insurers often have similar visual acuity requirements.
Insurance providers may also deny claims if there are other viable options to correct the patient’s vision instead of surgery. This includes updated prescription glasses or contacts. If the cataract is mild and other correction options would restore functional vision, insurers may require trying those first before approving surgery [2].
Cataract surgery may also be denied for patients deemed high risk, such as those with significant heart or lung conditions that make anesthesia unsafe. Insurers may require clearance from primary care doctors or cardiologists before approving surgery for high risk patients [3].
When Denials May Be Unjustified
Insurance companies may unjustly deny coverage for cataract surgery in cases where the surgery is the standard treatment and the patient has significant vision impairment. According to the American Optometric Association, cataracts are the leading cause of vision loss in people over age 40, and cataract surgery is one of the most common and successful operations in medicine (AOA).
Requiring prior authorization for a routine, effective procedure like cataract surgery can delay needed care. A study in Ophthalmology found that preauthorization requirements for cataract surgery increased wait times by 4 to 15 days (Healio). This extra wait can allow cataracts to progress, worsening vision impairment.
In cases where cataracts have significantly reduced visual acuity and surgery is the standard, recommended treatment, denial of coverage may be unjustified. Ophthalmologists argue that non-medical personnel should not override clinical judgement in these scenarios (BMJ).
Appealing the Denial
If your insurance denies coverage for cataract surgery, you have the right to appeal. There are two types of appeals – internal and external. An internal appeal is filed with your insurance company, while an external appeal is filed with an independent third party.
To start an internal appeal, contact your insurance company and explain why you disagree with their decision. Request an internal appeal form and submit it along with additional information from your doctor supporting the medical necessity of the surgery (Source). Provide complete medical records, a letter from your ophthalmologist explaining why the surgery is needed, and highlight relevant clinical practice guidelines.
The insurance company then re-reviews your case. If they uphold their denial, you can request an external appeal with an independent review organization. Your state insurance department can provide information on how to request an external appeal (Source).
State Laws
Coverage for cataract surgery can vary significantly depending on the state you live in and the type of insurance you have. Some states have passed laws mandating that insurance plans cover cataract surgery, while others leave it up to insurers to determine coverage. According to nVisionCenters, Medicaid plans are required to cover medically necessary treatment, but the specifics depend on state laws and regulations.
For example, California passed a law in 2012 requiring state-regulated health plans to cover treatment for pediatric congenital cataracts until age 19. Other states like Colorado and Kentucky have laws requiring insurers to cover cataract surgery without applying deductibles. Some states allow insurers to impose things like waiting periods, pre-authorizations, or exclusions for pre-existing conditions when it comes to cataract surgery.
On the consumer protection side, some states have laws prohibiting balance billing, which is when out-of-network providers bill patients for charges not covered by their insurer. There are also states that limit patient cost-sharing for cataract surgery to protect those with high deductible health plans.
Federal Protections
The Affordable Care Act (ACA) includes protections that can help ensure coverage for cataract surgery. The ACA prohibits health plans from denying coverage or increasing rates based on pre-existing conditions like cataracts. It also eliminated annual and lifetime limits on essential health benefits, which include vision coverage and eye care.[1]
The Employee Retirement Income Security Act (ERISA) provides additional protections for those with employer-sponsored health plans. ERISA establishes requirements for internal appeals processes that patients can pursue if initially denied cataract surgery coverage. Patients also have the right to request external review by an independent third party.[2]
In summary, federal laws like the ACA and ERISA help ensure access to medically necessary cataract surgery regardless of pre-existing conditions or initial coverage denials in many plans.
Alternatives if Denied
If your insurance company denies coverage for cataract surgery, you still have options to consider before paying the full price out-of-pocket. Here are some alternatives to explore:
Negotiate the cash price. Many facilities will offer a discount if you pay the entire bill upfront in cash. Ask about prompt pay or self-pay discounts to reduce the overall cost. Just be sure to get any discount agreement in writing first.
Consider medical tourism. Traveling abroad for low-cost cataract surgery is an option, but do your research. Ensure the facility is accredited and the surgeon is highly experienced in the procedure. Factor in travel and accommodation costs as well. Popular medical tourism destinations include Mexico, Costa Rica, and Thailand.
Enroll in a clinical trial. Research facilities near you that are conducting clinical trials for new cataract treatments. Participating in a study may give you free or reduced-cost access to cutting edge procedures not yet widely available. However, clinical trials come with risks and uncertain outcomes to consider.
While negotiating a lower cash price or looking into alternatives can help reduce the burden of paying out-of-pocket, cataract surgery is generally considered safe and effective. If your vision loss is significant, getting the necessary procedure done soon, even at full cost, may be worth the investment for your overall quality of life.
Outlook
The outlook on insurance coverage for cataract surgery is generally positive. While some insurance denials still occur, advocacy efforts are helping improve access and coverage. One major trend is the shift towards value-based care models that prioritize quality outcomes over volume of services. This benefits patients by incentivizing high-quality cataract surgery with good visual results. There is also a trend of using real-world data and studies to demonstrate the long-term cost savings and health benefits of cataract surgery, which helps justify coverage.
Patient advocacy groups like the American Academy of Ophthalmology are pushing for laws and protections to limit unfair denials for medically necessary cataract surgeries. They argue the surgeries meet the criteria for “medical necessity” in most cases and denials should be limited to rare exceptions. These efforts have helped enact state laws and model legislation that define cataract surgery coverage standards. Advocacy may also lead to refined federal protections and oversight from agencies like the Centers for Medicare & Medicaid Services.
In summary, while some challenges remain in securing coverage, the outlook is positive thanks to value-based care, data-driven studies, patient advocacy, and evolving legal protections. This suggests cataract surgery denials may continue declining in the years ahead.
Conclusion
Cataract surgery is a common procedure for many aging seniors, yet due to the high costs, insurance companies frequently deny claims to cover this surgery. When denials are warranted due to factors like lack of medical necessity or coverage limitations, patients unfortunately may need to cover surgery costs out-of-pocket, get on a payment plan with their provider, or delay the procedure. However, if a denial seems unjustified, patients have options to appeal the decision both internally and externally. Knowing state laws and federal protections can help patients understand their rights. While dealing with insurance denials can be frustrating, being an informed and proactive patient is key to getting coverage for needed procedures.
Insurers aim to control costs, but ethical companies should not deny truly necessary care. Patients should focus on providing all required documentation, understanding their specific policy, and appealing inappropriate denials. With perseverance and the help of medical providers, most who need cataract surgery can find reasonable ways to access this vision-restoring procedure.
