Petersburg, FL); and XACT Foldable Hydrophobic Acrylic Ultraviolet Light- Absorbing Posterior Chamber Intraocular Lens (Bausch & Lomb) are also considered medically necessary for aphakia.
(: Piggyback posterior chamber IOLs (i.e., placement of 2 IOLs in the same eye) are considered experimental and investigational).
Aetna considers the following IOLs non-covered deluxe items: Accommodating posterior chamber IOLs (e.g., Crystalens (Eyeonics Inc., Aliso Viejo, CA); multi-focal posterior chamber IOLs (e.g., Array Model SA40 (Abbott Medical Optics, Santa Ana, CA), Re Zoom (Abbott Medical Optics, Santa Ana, CA), Tecnis ZM900 and ZMAOO (Abbott Medical Optics, Santa Ana, CA), Acry Sof Re STOR, (Alcon Surgical, Fort Worth, TX), Acrysof Re STOR SA60D3 multifocal, Acrysof Natural Re STOR SN60D3, Acry Sof Re STOR Aspheric IOL model SN6AD1, Acry Sof Re STOR Aspheric IOL model SN6AD3); astigmatism-correcting (toric) posterior chamber IOLs (e.g., Staar Toric IOL (Star Surgical, Monrovia, CA), Staar Elastic Toric Lens Model AA4203TL, Abbott Medical Optics Tecnis Toric model ZCT150, Acry Sof Toric IOL (Alcon Surgical, Fort Worth, TX)) Acry Sof Aspheric Toric IOL SN6AT3, SN6AT4 and SN6AT5, Acry Sof Toric Models SA60T3, SA60T4 and SA60T5, Acry Sof Toric Model SA60T, and Acrysof IQ Toric Model SN6ATT, SN6AT6, SN6AT7 SN6AT8, and SN6AT9); multifocal astigmatism-correcting (toric) intraocular lens (Re STOR Multifocal Toric IOL); and accommodating toric intraocular lens (Trulign Toric IOL (Bausch & Lomb, Inc., Rochester, NY)).
For members who elect non-covered new technology IOLs, cataract removal and lens implantation would be considered medically necessary if the criteria for cataract surgery outlined above are met.
The new technology lens itself would be non-covered.
: An inpatient setting for cataract removal surgery generally is not considered medically necessary.
In addition to a comprehensive or brief/intermediate eye examination, A-mode ultrasound (A-scan) may be considered medically necessary prior to cataract surgery to determine the appropriate pseudophakic power of the IOL.
The pre-operative tests listed above are considered experimental and investigational in most cases before cataract surgery.
There is inadequate evidence that other pre-operative tests are useful in determining the need for cataract surgery, nor predict the benefits or adverse outcomes from cataract surgery.
* B-scan ultrasound is considered medically necessary in place of A-scan ultrasound where direct visualization of the retina is difficult or impossible including lid problems (e.g., severe edema, partial or total tarsorrhaphy), keratoprosthesis, corneal opacities (e.g., scars, severe edema), hyphema, hypopyon, miosis, dense cataract, pupillary membranes, or vitreous opacities (e.g., hemorrhage, inflammatory debris).
: Aetna considers standard fixed monofocal posterior chamber IOLs medically necessary for aphakia (e.g., Akreos posterior fixed monofocal IOL (Bausch & Lomb, Rochester, NY), Akreos AO Micro Incision Lens (Model MI60L), Acry Sof SA60AT monofocal IOL (Alcon Surgical, Fort Worth, TX), Acry Sof MA60AC, Acry Sof SN60AT, Alcon MZ30BD, Cee On Edge (Pharmacia Corp., Peepack, NJ) and the Hydroview hydrogel foldable posterior IOL (Bausch & Lomb, Rochester, NY)).
Standard posterior chamber IOL for hyperopia (e.g., Clariflex, Sensar AR40e, Advanced Medical Optics, Santa Ana, CA) is considered medically necessary.