Laser Surgery For Eyes Insurance Coverage For Refractive Surgery Position Statement

April 1999 medical insurance plans have many different provisions regarding payment for refractive surgery like PRK and LASIK. As a general rule, refractive surgery is considered as cosmetic surgery and is not covered. Under certain conditions, medical insurance plans will cover refractive surgery. Often the process of attaining coverage is confusing for both the insurance plan and the patient.

To assist patients and the medical insurance industry, CRSQA has provided a list of parameters under which we believe payment for refractive surgery is appropriate under a medical insurance plan. You may wish to print this information and provide it to your medical insurance plan.

Indications for Reimbursement

It is our opinion that absent the following conditions, refractive surgery would be an elective substitute for spectacles or contact lenses and should not be eligible for reimbursement under a medical insurance program.

We generally believe that medical insurance should provide reimbursement coverage for refractive surgery only where contributing pathology is present. We define contributing pathology as any one of the following:

Refractive errors that are induced by injury.
Refractive errors that are induced by surgery.
Anisometropia greater than 3 diopters.
Myopia greater than 10 diopters.
Hyperopia greater than 3 diopters.
Astigmatism greater than 3 diopters.
Inability to utilize spectacles due to physical limitation (allergy, deformity, et cetera) and inability to utilize contacts due to physical limitation (dry eyes, allergy, chronic infections, lens intolerance, et cetera).

Contraindications for Reimbursement

In the event pathology exists as defined above, restrictions on reimbursement for refractive surgery should be implemented if any one of the following also exist:

Patient is under 18 years of age.
Presence of disease that may cause continued unusual refractive change.
The primary purpose of the procedure is not to correct pathology ( i.e. cosmetic, occupational, experimental, or investigative).
Treatment of complications resulting from previous procedures not normally covered by medical insurance.
The use of a device not approved by the Food and Drug Administration.
Insufficient documentation to substantiate the procedure.

___________________________________________