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Laser Eye Surgery – Will Insurance Pay? Determining the Medical Necessity of “Cosmetic” Treatments
AllMed Healthcare Management
Eye wear may be a fashion accessory, but when you depend on it for seeing the world, it’s a lot more. Today, many people are turning to refractive laser eye surgery, such as Lasik surgery, to improve their vision. However, this high-cost surgery is normally not paid for by insurance because it fails to meet the conservative therapy test and is classified as cosmetic. This trend is shifting.
We are seeing an increasing number of circumstances where refractive eye surgery is determined to be medically necessary and, therefore, payable by the insurance provider. For example, if conservative therapy treatments fail or if a patient is intolerant of contact lenses and cannot wear glasses because they might pose a risk in their job (e.g. police or firefighters), refractive eye surgery may be the most medically viable treatment option.
Conservative Therapy Options:
Examples of conservative therapy treatments include the following:
Photorefractive keratectomy (PRK) – a refractive laser surgical procedure that is often done (and covered) for a patient that suffers from recurrent corneal erosion (e.g. diabetics). With PRK, a laser is used to remove corneal tissue to correct vision problems.
Patching, epithelial debridement (mechanical removal of faulty tissue), and bandaged contact lens placement – treatments that often don’t work.
Stromal puncturing – a procedure involving the physician puncturing the anterior corneal stroma – can also be used but can fail or result in permanent vision loss. In such cases, PRK is the best alternative for removing the damaged cells (or membranes) and possibly correcting the vision problems.
Physicians can help patients who are in medical need of laser eye surgery make a stronger case by initiating the following:
Document a full medical history of the patient’s eye complaints
Show proof that the patient has not responded to conservative treatments and that the purpose of the surgery is for medical reasons other than simply improved eyesight
Still, even when the physician does this, each decision is taken on a case-by-case basis and is subject to the extenuating circumstances clearly noted in the patient’s medical record.
For more information about medical necessity reviews on cases like this, visit our website or call us at 1-800-400-9916.
About The Author
AllMed Healthcare Management Founded in 1995, AllMed (http://www.allmedmd.com, http://www.allmedmd.com/blog/index.htm) is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers.
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