U.S. to allow private-pay option for presbyopia-correcting IOLs

Ophthalmologists and industry applaud the ‘forwardthinking’ policy adoption that grants Medicare benefi ciaries access to new technologies.

ByMichelle Dalton

WASHINGTON — Medicare patients in the United States who desire to have a presbyopia-correcting IOL implanted during cataract surgery now have the option to pay privately for the IOL, the U.S. Centers for Medicare and Medicaid Services has ruled.

Before the new ruling, Medicare rules “prevented benefi ciaries from receiving these lenses,” the CMS said in a statement. “Now benefi ciaries who choose to purchase this additional feature will be able to do so.”

The CMS statement noted that payment for conventional monofocal IOLs in an outpatient setting is now covered by Medicare. Providers have generally not offered presbyopia-correcting IOLs to Medicare benefi ciaries “because the costs for this advanced technology substantially exceed Medicare’s payment,” the CMS said.

For example, the standard Medicare reimbursement for a conventional IOL is US$200, but the suggested price for the eyeonics Crystalens is US$825, the price for Alcon’s AcrySof ReStor apodized diffractive IOL will be US$895 as that lens is introduced in the United States, and the ReZoom multifocal IOL from Advanced Medical Optics will be sold for US$895.

The CMS ruling clarifi es that a benefi ciary may request insertion of a presbyopia-correcting IOL in place of a conventional IOL following cataract surgery and elect to pay privately for the difference between these amounts.

“In this case, the presbyopia-correcting IOL device and associated services for fi tting one lens are considered partially covered by Medicare,” the CMS statement said. “The benefi ciary is responsible for payment of that portion of the charge for the presbyopiacorrecting IOL and associated services that exceed the charge for insertion of a conventional IOL.”

Long time coming

Eyeonics has worked with U.S. Congressman Christopher Cox, and CMS for more than 5 years to change the policy, the company noted in a press release.

“The eyeonics case had been working its way through the system for some time before I got involved,” Rep. Cox said in an interview with Ocular Surgery News. He said CMS faces the challenge of controlling costs, and some of its decisions are based on budgetary concerns rather than medical needs.

Rep. Cox said he pointed out to CMS administrator Mark B. McClellan, MD, PhD, that one option would be to allow the Medicare provider to charge the beneficiary the difference between the cost of the non-covered service and the customary payment for the covered service. This is essentially what the CMS did in its ruling, which took effect May 3.

When CMS issued its policy on presbyopia-correcting IOLs, “it was a great day for patients, ophthalmologists and our industry,” said J. Andy Corley, chairman and chief executive officer of eyeonics.

“We’ve always been committed to private payment for the procedure,” Mr. Corley said. “We never believed government should pay for elective, noncovered benefi ts. We do believe that a patient has the right to choose non-covered benefits and pay privately.”

Patient options

The decision by CMS to allow private payment by Medicare benefi ciaries for presbyopia-correcting IOLs has no downside, both physicians and industry members said.

“This CMS decision removes a barrier and enables ophthalmologists to use a powerful new technology to further improve the quality of patient’s lives,” said ASCRS President Roger F. Steinert, MD, in a press release from ASCRS. “By allowing patients to pay for the procedure, the decision encourages the marketplace to invest in research to fully explore the possibilities that high technology lenses offer.”

Andy Stapars, director of government operations for Advanced Medical Optics, agreed. “Manufacturers will be appropriately paid for their investment in research and development and will continue to bring new and better technology to the marketplace,” Mr. Stapars said.

Alcon representatives also praised the CMS decision for increasing Medicare patients’ options.

“We applaud CMS for its decision to allow Medicare patients access to new technologies, which provide a high level of spectacle freedom … ,” said Cary Rayment, chairman, president and chief executive offi cer of Alcon, in a press release.

Added James V. Mazzo, president and chief executive offi cer of AMO, in a separate press release, “This provides an important new opportunity for Medicare cataract patients to enjoy a full range of distance, intermediate and near vision after surgery.”

For Your Information:

J. Andy Corley, president and chief executive officer of eyeonics, can be reached at 6 Journey, Suite 125, Aliso Viejo, CA 92656 U.S.A.; Web site: www.eyeonics.com; email: jacorley@eyeonics.com.
Rep. Christopher Cox can be reached at 2402 Rayburn HOB, Washington, DC 20515 U.S.A.; +1-202-225-5611; Web site: www.cox.house.gov.

Andy Stapars, director of government relations for Advanced Medical Optics, can be reached at 1700 E. St. Andrew Place, P.O. Box 25162, Santa Ana, CA 92799-5162 U.S.A.; +1-817-488-3309; e-mail: andy.stapars@amo-inc.com.
Alan E. Reider, JD, can be reached at Arent Fox PLLC, 1050 Connecticut Ave. NW, Washington, DC 20036 U.S.A.; +1-202-857-6462; e-mail: Reider.alan@ArentFox.com.

Eyeonics, maker of the Crystalens, can be reached at 6 Journey, Suite 125, Aliso Viejo, CA 92656 U.S.A.; fax: +1-949-716-8362; Web site: www.eyeonics.com.
Advanced Medical Optics, maker of the ReZoom lens, can be reached at 1700 E. St. Andrew Place, P.O. Box 25162, Santa Ana, CA 92799-5162 U.S.A.; +1-714-247-8200; Web site: amo-inc.com.

Alcon, maker of the AcrySof ReStor IOL, can be reached at 6201 South Freeway, Fort Worth, TX 76134 U.S.A.; +1-817-293-0450; Web site: www.alconlabs.com.

Michelle Dalton Liberatore is the Managing Editor of the OSN SuperSite.com. She writes daily updates on developments in all aspects of ophthalmology.