Astigmatism-correcting and Presbyopia-correcting Intraocular Lenses (ACIOLs/PIOLs)
Defines medical necessity and coverage rules for ACIOLs and PIOLs used during cataract surgery for Premera Blue Cross members, and explains cost-sharing where specialty lens incremental costs are borne by the patient.
No material clinical or coverage changes in this revision.
Coverage Criteria for ACIOLs and PIOLs
Medical necessity for PIOLs and ACIOLs
Covered when ALL of the following are met
The Plan will pay the portion of the lens cost equal to the cost of conventional IOLs; any additional specialty lens cost is the responsibility of the individual. Providers must document that a conventional IOL insertion is being performed during cataract surgery and, if delivering a specialty PIOL/ACIOL, document member acknowledgement that the incremental cost above a standard IOL is the patient's responsibility.
The Plan does not cover the additional cost of presbyopia-correcting intraocular lenses (PIOLs) or astigmatism-correcting intraocular lenses (ACIOLs) that exceeds the cost of a standard intraocular lens (IOL). If the member elects a specialty lens and is charged an amount above the standard IOL cost, that incremental expense is the patient's financial responsibility and is not payable by the Plan.
Procedural and HCPCS/CPT Coding
| 66982 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (complex) |
| 66983 | Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage) |
| 66984 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (routine) |
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