CurrentKaiser PermanentePolicy N/A

Kaiser Foundation Health Plan of Washington Clinical Review Criteria

Defines Kaiser Permanente of Washington clinical review criteria for coverage of intraocular lenses (IOLs) following cataract surgery, specifying that standard monofocal IOLs are covered, multifocal and accommodative IOLs are not covered as medically necessary, and toric/presbyopia/astigmatism-correcting lens functions are considered not medically necessary. Includes required documentation for review and references to Medicare LCD/NCD positions.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy CodePolicy N/A

Change TypeAdded criteria for Toric Intraocular Lens

Effective DateAug 1, 2005

Next Review Date

Key ActionWhen requesting review for these services (e.g., multifocal or accommodative IOL), submit the last 6 months of clinical notes from the requesting provider and/or specialist.

POLICY UPDATE CHANGES

Added criteria for Toric Intraocular Lens

1Covered IOL type (monofocal)

3IOL types not medically necessary

2Medicare references cited

Coverage Summary

Defines Kaiser Permanente of Washington clinical review criteria for coverage of intraocular lenses (IOLs) following cataract surgery. Standard monofocal IOLs are covered, while multifocal, accommodative, and toric/presbyopia- or astigmatism-correcting lens functions are considered not medically necessary. MTAC evidence found multifocal IOLs improve near vision but have tradeoffs (glare, halos, reduced contrast), and accommodative IOLs do not meet MTAC criteria due to insufficient or inconsistent long-term efficacy evidence. Effective date: 2005-08-01; Last review: 2024-08-06.

Coverage Criteria and Documentation Requirements

Covered / Not Covered IOL Types

Coverage determinations for intraocular lenses following cataract surgery:

ALL of the following

Covered
- Standard monofocal intraocular lenses are covered following cataract surgery
  Patient may need spectacles for near vision
Not covered / Considered not medically necessary
- Multifocal intraocular lenses will not be covered
  Patient may elect to pay for the multifocal lens (elective/self-pay)
- Accommodative intraocular lenses do not meet Kaiser Permanente Medical Technology Assessment Criteria and are not covered
  Insufficient evidence of safety and long-term efficacy compared to standard IOLs
- Toric intraocular lenses to correct astigmatism are not covered
  Purpose is to reduce dependence on glasses; additional benefit beyond standard cataract surgery is not a covered service

Documentation Required for Review

If requesting review for not-routinely covered services, submit:

Required documentation for review requests: Last 6 months of clinical notes from requesting provider and/or specialist

Required documentation for review requests

Provider Actions / Billing Impact

Documentation Required

Submit clinical notes for review

When requesting review for these services (e.g., multifocal or accommodative IOL), submit the last 6 months of clinical notes from the requesting provider and/or specialist.

Include the last 6 months of clinical notes from the requesting provider and/or specialist.

Prior Authorization

Verify authorization requirements

To verify authorization requirements for a specific code by plan type, use the Pre-authorization Code Check.

Use the Pre-authorization Code Check to confirm authorization requirements by plan type.

Denial Risk

Noncovered lens functions

Claims reporting HCPCS codes V2787 or V2788 (astigmatism- or presbyopia-correcting functions) are considered not medically necessary and may be denied.

Affected HCPCS codes: V2787, V2788 — these functions are considered not medically necessary and may be denied.

Background and Evidence

Background: Cataract affects millions (estimated >20 million Americans over age 40, projected to rise). Cataract treatment replaces the natural lens with an intraocular lens (IOL). IOL designs include monofocal lenses (provide excellent distance vision but usually require spectacles for near tasks), multifocal lenses (bifocal/multifocal designs aim to provide functional distance, intermediate, and near vision), accommodative lenses (designed to shift position or optical power in response to ciliary muscle contraction to provide some accommodation), and toric lenses (designed to correct corneal astigmatism). MTAC evidence conclusions: multifocal IOLs improve uncorrected near visual acuity and increase spectacle independence but are associated with decreased contrast sensitivity and higher rates of glare and halos—benefits must be weighed against these tradeoffs. Accommodative IOLs have limited and variable measured accommodative effect and the MTAC concluded evidence is insufficient or does not meet criteria for long-term efficacy and safety.

Evidence (MTAC conclusions)

MTAC conclusion - Multifocal IOLUse meets Kaiser Permanente Medical Technology Assessment Criteria for visual correction following cataract surgery (improves near vision; tradeoffs exist such as glare, halos, decreased contrast sensitivity)

MTAC conclusion - Accommodative IOLUse does not meet Kaiser Permanente Medical Technology Assessment Criteria (insufficient evidence of safety and long-term efficacy)

Definitions: Multifocal intraocular lens — an IOL designed (refractive or diffractive) to provide functional distance, intermediate, and near vision but associated with increased glare/halos and decreased contrast sensitivity. Accommodative intraocular lens — an IOL engineered to change position or optical power (optic-shift via haptics/hinges) in response to ciliary muscle contraction to provide accommodation; objective accommodative effect is limited, variable, and long-term efficacy evidence is insufficient. Toric intraocular lens — an IOL designed to correct corneal astigmatism and reduce dependence on glasses; considered elective and not covered.

Name	Number	Type
Intraocular Lens	80.12	NCD
Hydrophilic soft contact lenses as corneal dressing	V2520-V2523	LCD
Refractive Lenses	A52499	LCA