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CMS allows private-pay option for presbyopia-correcting IOLs
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WASHINGTON — Medicare patients who desire to have a presbyopia-correcting IOL implanted during cataract surgery now have the option to pay privately for the IOL, the Centers for Medicare and Medicaid Services has ruled.
Before the new ruling, Medicare rules “prevented beneficiaries from receiving these lenses,” the CMS said in a statement. “Now beneficiaries 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 beneficiaries “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 $200, but the suggested price for the eyeonics Crystalens is $825, the price for Alcon’s AcrySof ReStor apodized diffractive IOL will be $875 as that lens is introduced in the United States, and the ReZoom multifocal IOL from Advanced Medical Optics will be sold for $895.
The Crystalens was approved by the Food and Drug Administration for marketing in the United States in November 2003. The AcrySof ReStor and the AMO ReZoom were approved in March 2005. Until this CMS ruling, the status of Medicare reimbursement for these IOLs has been the subject of debate.
The CMS ruling clarifies that a beneficiary 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 fitting one lens are considered partially covered by Medicare,” the CMS statement said. “The beneficiary is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL.”
Long time coming
Eyeonics has worked with Congressman Christopher Cox, R.-Calif., 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.
“Medicare can’t pay for Cadillac services. It’ll pay for a Chevy,” he said. “So eyeonics asked them to pay for a Chevy and Medicare said ‘no.’”
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.
Value issues
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, non-covered benefits. We do believe that a patient has the right to choose non-covered benefits and pay privately.”
He added that his company does not control the physician’s charge for the procedure.
“The average [charge for] the Crystalens procedure is $4,500 an eye, plus $1,000 in the event of a complicated case,” he told OSN. Complicated cases might include patients with more than 2 D of astigmatism or with previous refractive surgery.
The free market system will determine the success of presbyopia-correcting IOLs, said Louis D. “Skip” Nichamin, MD. Dr. Nichamin is the chairman of the Cataract Clinical Committee of the American Society of Cataract and Refractive Surgery.
“The performance of the lenses will be crucial to the market adoption rate,” Dr. Nichamin said in an interview with OSN.
He said he sees a trend towards more patients opting for accommodative lenses rather than conventional IOLs, “but that will be married with the performance of the lenses.”
Patient options
The decision by CMS to allow private payment by Medicare beneficiaries for presbyopia-correcting IOLs has no downside, both physicians and industry said.
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.
Mr. Stapars is AMO’s representative in the Industry Coalition for the Advancement of Restorative Eyecare (ICARE), a collaborative effort of AMO, Alcon and Bausch & Lomb, which has lobbied CMS regarding this issue.
“This [change in policy] would not have happened but for the vision and relentless pursuit of this policy change by eyeonics,” Mr. Stapars told OSN. “Eyeonics really championed the concept and brought it to the forefront by bringing in Congressman Cox as well.”
This article was also published in Ocular Surgery News, a Slack Inc. publication.
For Your Information:
- Rep. Christopher Cox can be reached at 2402 Rayburn HOB, Washington, DC 20515; 202-225-5611; or at 1 Newport Place, Suite 1010, Newport Beach, CA 92660; 949-756-2244; Web site: www.cox.house.gov.
- J. Andy Corley, chairman and chief executive officer of eyeonics, can be reached at 6 Journey, Suite 125, Aliso Viejo, CA 92656; 866-393-6642; fax: 949-716-8362; Web site: www.eyeonics.com; email: jacorley@eyeonics.com.
- Louis D. “Skip” Nichamin, MD, can be reached at Laurel Eye Clinic, 50 Waterford Pike, Brookville, PA 15825; 814-849-8344; fax: 814-849-7130; e-mail: nichamin@laureleye.com.
- 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; 817-488-3309; fax: 817-488-2679; e-mail: andy.stapars@amo-inc.com.
- eyeonics, maker of the Crystalens, can be reached at 6 Journey, Suite 125, Aliso Viejo, CA 92656; 866-393-6642; fax: 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; 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; 817-293-0450; Web site: www.alconlabs.com.