CurrentCignaPolicy 0125

Intraocular lens (IOL) implants

Defines medical necessity, exclusions, replacement indications, and coding for intraocular lens (IOL) implants (standard monofocal and premium/other IOL types) for Cigna-administered health benefit plans. Applies to surgical implantation and replacement of IOLs and lists covered and not-covered diagnosis and procedure codes.

Policy Summary

PayerCigna

PolicyIntraocular lens (IOL) implants

Policy CodePolicy 0125

Change TypeFocused review (11/12/2023); Annual review (09/15/2024)

Effective DateSep 15, 2024

Next Review DateSep 15, 2025

Key ActionProvider must document the specific covered indication (e.g., cataract extraction, trauma, congenital cataract/aphakia, lens subluxation/displacement, anisometropia >=2 D uncorrectable with glasses/contact lenses) to support medical necessity.

POLICY UPDATE CHANGES

Added policy statement for standard monofocal intraocular lens.

Revised policy statement for premium intraocular lens.

Removed policy statement for intraocular lens implant following clear lens extraction.

Annual review with no clinical policy statement changes.

6Covered Indications listed

3Excluded premium/phakic lens types

~40ICD-10 codes listed

Scope: Defines medical necessity, exclusions, replacement indications, and coding for intraocular lens (IOL) implants (standard monofocal and premium/other IOL types) for Cigna-administered health benefit plans. Applies to surgical implantation and replacement of IOLs and lists covered and not-covered diagnosis and procedure codes.

High-level summary: Standard monofocal IOLs are considered medically necessary for listed indications (e.g., following cataract extraction, trauma with lens damage, congenital cataract or congenital aphakia, lens subluxation/displacement, and anisometropia of >= 2 diopters uncorrectable with glasses or contact lenses). Premium IOLs (e.g., presbyopia-correcting, astigmatism-correcting/toric functions in many plans, and phakic IOLs) are intended to reduce dependence on glasses and are considered convenience items/excluded or not medically necessary in many plans.

Status and review dates: Policy status is CURRENT. Effective Date: 9/15/2024; Last Review: 9/15/2024; Next Review: 9/15/2025.

Threshold and quick facts

Anisometropia coverage threshold>= 2 diopters and uncorrectable with glasses or contact lenses

Covered indications (count)6 listed (cataract extraction, trauma-damaged lens, congenital cataract, congenital aphakia, lens subluxation/displacement, anisometropia >=2 D)

Commonly excluded premium/phakic lens types (count)3 listed (presbyopia-correcting IOL, astigmatism-correcting IOL, phakic IOL)

ICD-10 codes listed (approximate count)~40 codes/ranges listed

Policy number0125

Policy subjectIntraocular lens (IOL) implants

Policy statusCURRENT (Effective 9/15/2024; Annual review 9/15/2024)

Medical Necessity Criteria

Standard monofocal IOL — Medically Necessary

Standard monofocal intraocular lens (IOL) implant is considered medically necessary for ANY of the following conditions:

ANY of the following

following cataract extraction
trauma to the eye which has damaged the lens
congenital cataract
congenital aphakia
lens subluxation/displacement
Anisometropia threshold: anisometropia of 2 diopters or greater, and uncorrectable vision with the use of glasses or contact lenses>= 2 D and uncorrectable with glasses or contact lenses

Standard monofocal IOL — Not covered

Standard monofocal intraocular lens (IOL) implant for any indication not listed above

Standard monofocal IOL implant for any indication not listed in the medically necessary list is not covered or reimbursable.

Premium IOLs — Not medically necessary / Excluded in many plans

Premium intraocular lens implants are intended to reduce the need for reading glasses and are considered convenience items; excluded or not covered for any indication in many plans:

ANY of the following

presbyopia correcting IOL (e.g., multifocal, EDOF/presbyopia-correcting lenses)
astigmatism correcting IOL (toric function listed as excluded in many plans)
phakic IOL

Replacement of implanted IOL — Medically Necessary

Replacement of a previously implanted IOL is considered medically necessary when ANY of the following render the lens ineffective or nonfunctional:

ANY of the following

anatomical change renders previously implanted IOL ineffective or nonfunctional
inflammatory response renders previously implanted IOL ineffective or nonfunctional
mechanical failure renders previously implanted IOL ineffective or nonfunctional

Coding

Considered Medically Necessary when criteria met - Procedure codesCPTCovered

66985	Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal.
66986	Exchange of intraocular lens

Considered Medically Necessary when criteria met - HCPCS / Device codesHCPCSCovered

C1780	Lens, intraocular (new technology)
V2630	Anterior chamber intraocular lens
V2631	Iris supported intraocular lens
V2632	Posterior chamber intraocular lens
0276	Intraocular lens

Considered Medically Necessary when criteria met - ICD-10 Diagnosis codes (covered indications)ICD-10Covered

E08.36	Diabetes mellitus due to underlying condition with diabetic cataract
E09.36	Drug or chemical induced diabetes mellitus with diabetic cataract
E10.36	Type 1 diabetes mellitus with diabetic cataract
E11.36	Type 2 diabetes mellitus with diabetic cataract
E13.36	Other specified diabetes mellitus with diabetic cataract
H25.011-H25.013	Cortical age-related cataract
H25.031-H25.039	Anterior subcapsular polar age-related cataract
H25.041-H25.049	Posterior subcapsular polar age-related cataract
H25.091-H25.099	Other age-related incipient cataract
H25.11-H25.13	Age-related nuclear cataract

1–10 of 37

1/4

Not Covered or Reimbursable - ICD-10 (refractive-only indications)ICD-10Not Covered

H52.00-H52.03	Hypermetropia
H52.10-H52.13	Myopia
H52.201-H52.209	Unspecified astigmatism
H52.211-H52.219	Irregular astigmatism
H52.221-H52.229	Regular astigmatism
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511-H52.519	Internal ophthalmoplegia (complete) (total)
H52.521-H52.529	Paresis of accommodation
H52.531-H52.539	Spasm of accommodation

1–10 of 12

1/2

Provider Actions

Documentation Required

Document indication for IOL

Provider must document the specific covered indication to support medical necessity for an intraocular lens (IOL) implant. The indication should match one of the covered indications listed in this policy.

Cataract extraction
Trauma to the eye which has damaged the lens
Congenital cataract or congenital aphakia
Lens subluxation/displacement
Anisometropia ≥ 2 diopters and uncorrectable with glasses or contact lenses

Billing Rule

Use appropriate codes

When billing, providers must use the most appropriate (current) CPT/HCPCS/ICD-10 codes as of the date of service. Claims for services not accompanied by covered code(s) under this policy will be denied as not covered.

Claims without covered codes under this policy will be denied as not covered.

Background & Definitions

Background: Most IOL implants are used during cataract surgery to replace the eye's natural lens; cataracts are the most common indication and may be age-related, congenital, traumatic, or related to systemic disease or medications. Monofocal IOLs are the standard treatment and are set to focus at a single focal point (usually distance) and do not correct astigmatism or provide focusing at varying distances.

Monofocal versus premium IOLs: Monofocal lenses meet basic functional needs after cataract removal and typically require glasses for near or intermediate tasks. Premium (non-monofocal) lenses — including multifocal, accommodative, extended depth of focus (EDOF), light-adjustable, toric (astigmatism-correcting), and other presbyopia-correcting designs — are intended to reduce dependence on glasses but may have tradeoffs (e.g., decreased contrast sensitivity, more visual phenomena) and are considered not medically necessary or excluded in many plans.

Clinical context and convenience items: Some premium lenses (for example, phakic IOLs implanted without removing the natural lens to correct refractive error) are used primarily for refractive management rather than restoration of lens function after cataract extraction and are excluded in many benefit plans. Choice of IOL depends on physician recommendation and patient visual needs and expectations.

Term	Definition
Monofocal IOL
A lens set to focus at a single focal point (usually distance); does not correct astigmatism or provide focusing at varying distances.
Premium IOL
Non-monofocal lenses (e.g., multifocal, accommodative, EDOF, presbyopia-correcting, toric) intended to reduce need for glasses; considered not medically necessary in many plans.
Phakic IOL
An IOL implanted without removing the natural lens, used primarily for refractive correction (myopia); excluded in many plans.

AAO Toric Monofocal report (2024): Toric monofocal IOLs are effective in neutralizing pre-existing corneal astigmatism and improve uncorrected distance visual acuity compared with nontoric monofocal IOLs.

AAO Multifocal/Accommodating report (2021): Presbyopia-correcting lenses improve distance and near acuity and increase patient-reported spectacle independence but are associated with decreased contrast sensitivity and increased visual phenomena versus monofocal lenses.

Systematic and peer-reviewed literature summaries: Published evidence generally supports improved visual acuity and reduced need for eyeglasses with premium lenses, while also documenting trade-offs in contrast sensitivity and visual symptoms.

Policy literature note: The Coverage Policy cites randomized trials, systematic reviews, and technology assessments to inform distinctions between monofocal and premium IOL outcomes and the policy stance that premium lenses are often considered convenience items.

effective date	name	number	type
1997-05-19
Intraocular Lenses (IOLs)
80.12
NCD

No Determination found

LCD

Revision History

11/12/2023clarified

Focused Review dated 11/12/2023 added policy statement for standard monofocal intraocular lens (Added policy statement for standard monofocal intraocular lens).

11/12/2023revised

Focused Review dated 11/12/2023 revised policy statement for premium intraocular lens (Updated language noting premium IOLs are not medically necessary/convenience items).

11/12/2023removed

Focused Review dated 11/12/2023 removed prior policy statement regarding intraocular lens implant following clear lens extraction (Removed policy statement for IOL after clear lens extraction).

9/15/2024annual_reviewLatest

Annual Review dated 9/15/2024 — No clinical policy statement changes.

OpenPayer

Intraocular lens (IOL) implants

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions

Background & Definitions

Medicare Determinations

Revision History