March 2016
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE at the end of this document
For Medicaid Plans: Please refer to the appropriate State’s Medicaid manual(s), publication(s), citation(s), and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net
Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage guidelines first:
Use Source Reference/Website Link
X National Coverage Determination
(NCD)
Intraocular Lenses (IOLs) [80.12]
National Coverage Manual Citation
Local Coverage Determination (LCD) *
Article (Local) *
X Other Medicare Learning Matters Network. Instructions for Implementing the Centers for Medicare &
Medicaid (CMS) Ruling CMS 1536-R;
Astigmatism-Correcting Intraocular Lens (A-C
IOLs): http://www.cms.gov/MLNMattersArticles/downlo ads/MM5527.pdf
CMS Ruling #1536-R: http://www.cms.gov/Rulings/downloads/CMS15
36R.pdf http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/ASCPayment/NTIOLs.html http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/VisionServices_FactShe et_ICN907165.pdf
http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-
Payment/HospitalOutpatientPPS/Downloads/PCIOL-
Accommodating Intraocular Lens Mar 16 1

ACIOL.pdf
CMS Manual System. Department of Health & Human
Services (DHHS). Pub 100-04 Medicare Claims
Processing. Transmittal 914. Date: APRIL 21, 2006
Change Request 4361. SUBJECT: Additional $50
Payment for New Technology Intraocular Lenses
(NTIOLs) Furnished in Ambulatory Surgical Centers
(ASCs): https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/downloads/R914CP.
pdf
None Use Health Net Policy
Instructions
 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS
Manual Chapter 4 Section 90.2)
 If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual.
 If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.
Health Net, Inc. considers the use of premium multifocal intraocular lenses (IOLs), presbyopic-correcting lenses, astigmatism-correcting lenses (aspheric, toric), or accommodating IOLs following cataract extraction not medically necessary. These lenses do not offer a superior medical benefit for these lenses over the monofocal
IOL other than decreasing the need for corrective eye wear.
NOTE: Health Net will provide reimbursement for the cost of conventional
(standard) or monofocal IOLs post cataract extraction. However, members may choose to receive a premium lens but must agree to assume liability for the additional expense related to these lenses.
NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.
366.00– 366.90 Cataract
743.30- 743.39 Congenital cataract and lens anomalies
Accommodating Intraocular Lens Mar 16 2

E08.36
E09.36
E10.36
E11.36
E13.36
H25.011-H25.9
H26.001-H26.09
H26.101-H26.139
H26.20
H26.211-H26.219
H26.221-H26.229
H26.231-H26.239
H26.411-H26.419
H26.30-H26.33
H26.40
H26.491-H26.499
H26.8
Diabetes mellitus due to underlying conditions with diabetic cataract
Drug or chemical induced diabetes mellitus with diabetic cataract
Type 1 diabetes mellitus with diabetic cataract
Type 2 diabetes mellitus with diabetic cataract
Other specified diabetes mellitus with diabetic cataract
Age related cataract, code range
Infantile and juvenile cataract, code range
Traumatic cataract, code range
Unspecified complicated cataract
Cataract with neovascularization
Cataract secondary to ocular disorders (degenerative)
(inflammatory)
Glaucomatous flecks (subcapsular)
Soemmering’s ring
Drug-induced cataract
Unspecified secondary cataract
Other secondary cataract
Other specified cataract
H26.9
H28
Unspecified cataract
Cataract in diseases classified elsewhere
66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis
(one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage
66983 Intracapsular cataract extraction with insertion of intraocular lens
prosthesis (one stage procedure)
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis
(one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)
66985 Insertion of intraocular lens prosthesis (secondary implant), not associated
with concurrent cataract removal
66986 Exchange of intraocular lens
C1780 Lens, intraocular (new technology)
Q1004 New technology intraocular lens category 4 as defined in Federal Register notice
Q1005 New technology intraocular lens category 5 as defined in Federal Register
V2630 notice
Anterior chamber intraocular lens
V2631 Iris supported intraocular lens
V2632 Posterior chamber intraocular lens
Premium Lenses
S0596 Phakic intraocular lens for correction of refractive error
V2787 Astigmatism-correcting function of an intraocular lens
Accommodating Intraocular Lens Mar 16 3

V2788 Presbyopia correcting function of intraocular lens
Monofocal intraocular lens (IOL) are standard replacement lenses implanted after cataract surgery and usually have a fixed focusing power designed for either near or distance vision. The placement of a monofocal IOL usually requires corrective lenses or eyeglasses after surgery.
Premium Lenses
Multifocal IOLs are designed to provide near and far vision simultaneously thru the use either diffrative or refractive techniques to distribute light to distance, intermediate or near focal points depending on the amount of ambient light.
Intermediate vision is usually compromised and issues regarding glare, halos, variable loss of clarity and low contrast acuity have been reported by patients.
Presbyopia correcting lenses (e.g. multifocal, pseudoaccommodating) with or without additional features (e.g., toric, aspheric, ultraviolet protection), have been developed to improve visual acuity and may be referred to as premium IOLs.
Examples of P-C
IOLs include various models of TECNIS multifocal acrylic and silicone lens, ReZoom,
Acrysof ReSOTR.
Toric IOL are astigmatism-correcting intraocular lenses that provide correction or reduction of pre-existing astigmatism by incorporating a special curvature into the
IOL. Examples of A-C IOLs include various models of TENSIS Toric, Acrysof IQ Toric,
Trulign Toric and STAAR Toric.
Accommodating IOLs have hinges on both ends of the lens to facilitate flexion/contraction of the ciliary body by changing the position the lens (rather than shape) with the intent of allowing focus for distance, intermediate to near vision.
Crystalens is an example of an accommodating IOL.
Dhital et al (2013) compared visual acuity, intraocular lens (IOL) movement, and depth of focus with the Crystalens HD single-optic accommodating IOL and the
Tecnis ZCB00 aspheric monofocal IOL at a single center in a prospective randomized controlled trial. Patients with bilateral symptomatic cataract had bilateral sequential cataract surgery within 6 weeks with randomized implantation of the accommodating or monofocal IOL in both eyes. Exclusion criteria included other ocular conditions and corneal astigmatism greater than 2.00 diopters. The primary outcome was uniocular distance-corrected near visual acuity (DCNVA). Secondary measures were IOL movement, depth of focus, intermediate and distance vision, objective refraction, and pupil size at distance and near fixation. Results from 3 months postoperatively are presented. Three months postoperatively, 64 patients (32 in each group) were available for study. The distance vision was not statistically significantly different between the accommodating IOL and monofocal IOL (mean 0.05 logMAR versus 0.06 logMAR). The mean DCNVA (0.48 logMAR ± 0.15 [SD] versus 0.61 ± 0.13 logMAR) and intermediate visual acuity (0.08 ± 0.1 logMAR versus 0.20 ± 0.09 logMAR) were significantly better with the accommodating IOL (P<.001). Neither IOL had clinically significant movement, and near vision did not directly correlate with movement of the accommodating IOL. The accommodating IOL provided greater depth of focus.
Investigators concluded near and intermediate acuities were better with the accommodating IOL. This effect was not directly linked to IOL movement but was at least partly due to depth of focus.
Ang et al (2013) compared the visual acuity and quality of vision achieved with three widely-usedIOLs in subjects with bilateral cataracts. This three-arm, parallel,
Accommodating Intraocular Lens Mar 16 4

prospective, partially masked, single-surgeon study randomized 78 subjects to receive bilateral Crystalens Advanced Optics (AO) accommodating IOLs, AcrySof IQ
ReSTOR +3.0 multifocal IOLs, or TECNIS Multifocal IOLs. Examinations were assessed through days 120 to 180. The Crystalens AO group had statistically significantly better monocular and binocular, high-contrast (HC) and low-contrast
(LC) uncorrected intermediate visual acuity, HC and LC distance-corrected intermediate visual acuity, and significantly fewer monocular and binocular halos and starbursts than did the ReSTOR and TECNIS groups. Monocular and binocular, HC and LC uncorrected near visual acuity exhibited no significant differences among the three lenses. For monocular and binocular HC distance-corrected near visual acuity, the Crystalens AO performed significantly better than the TECNIS and was not significantly different from the ReSTOR. For monocular and binocular LC distancecorrected near visual acuity, the Crystalens AO performed significantly better than both the ReSTOR and the TECNIS. Contrast sensitivity was clinically similar between groups. The Crystalens AO produced statistically fewer halos and starbursts.
Investigators concluded all three IOLs had excellent uncorrected acuity results at all distances and had good safety, confirming the established safety and effectiveness of these IOLs. Distance and near vision were similar between all three IOLs, and the
Crystalens AO provided statistically significantly better intermediate vision.
Zamora-Alejo et al (2013) performed an evaluation of accommodation with a bilateral accommodating IOL versus monofocal IOLs. Patients received accommodating IOL (Crystalens HD) bilaterally after cataract surgery. These were compared to a matched group receiving monofocal IOLs. Preoperative and postoperative distance corrected distance, intermediate, and near vision were evaluated. Objective accommodation was measured with the WAM-5500 Binocular
Autorefractor/Keratometer (Grand Seiko, Pty Ltd., Hiroshima, Japan). Nineteen patients were included. Ten received the Crystalens HD in both eyes and nine received one of three monofocal lenses in each eye. Mean postoperative distance corrected distance visual acuity was not statistically different between the two groups. Mean distance corrected intermediate vision was better in the Crystalens HD group (logMAR 0.24 ± 0.11 [control], logMAR 0.11 ± 0.10 [Crystalens HD], P =
.033). The groups did not differ significantly for mean distance corrected near vision
(logMAR 0.54 ± 0.12 [control], logMAR 0.42 ± 0.15 [Crystalens HD], P = .087).
However, a significantly greater proportion of Crystalens HD eyes achieved 0.4 or
0.3 logMAR for near wearing their distance correction (P = .013). With distance correction, the mean spherical equivalent failed to show any myopia with accommodative effort in either group. Low contrast and low luminance contrast acuity were not significantly different. Investigators concluded the Crystalens HD showed some benefit for intermediate visual function compared to the monofocal
IOLs with both groups wearing full correction for distance. There were no significant signs of accommodation in either group.
Beiko et al (2013) compared near vision and quality of vision after controlling for pseudoaccommodation in patients with single-optic accommodating IOLs or monofocal IOLs targeted for mini-monovision in a prospective randomized controlled clinical trial. Patients were randomized to bilateral implantation of the Crystalens HD silicone accommodating IOL, the Tetraflex acrylic accommodating IOL, or the Tecnis
1-piece monofocal (nonaccommodating) control IOL. The target refraction for the control group was mini-monovision (-0.25 diopter [D] and -0.75 D). In the accommodating IOL groups, manufacturer recommendations were followed; that is, a target refraction of mini-monovision (-0.25 D and -0.75 D) in the acrylic accommodating group and +0.25 D in the silicone accommodating group. Pupil size and anterior corneal spherical aberration were measured preoperatively. Main outcome measures were binocular target refraction corrected near vision and contrast sensitivity 3 months postoperatively. There were no statistically significant
Accommodating Intraocular Lens Mar 16 5

differences between the 3 groups in age, photopic or mesopic pupil size, anterior corneal spherical aberration, corneal astigmatism, or the power of the IOLs implanted. Binocular distance visual acuity at 4 m was 20/20(-) in all groups, intermediate vision was approximately 20/25, and near vision was 20/40 to 20/50.
There were no statistically significant differences between the 3 groups in visual acuity or contrast sensitivity. Investigators concluded single-optic accommodating
IOLs did not offer a significant advantage in near visual acuity over mini-monovision with a monofocal (nonaccommodating) IOL.
Lubinski et al (2011) evaluated 3 and 6 months binocular visual outcomes after cataract surgery using a multifocal IOL "mix and match" approach, with a refractive
(ReZoom) IOL in the dominant eye and a diffractive (Tecnis) IOL in the fellow eye.
Three and 6 months after bilateral cataract surgery, 40 eyes of 20 patients were evaluated for binocular UDVA, UNVA and UIVA (logMAR), spectacle independence, contrast sensitivities (CS), stereoscopic vision, subjective symptoms, patient satisfaction and complications. Three months after surgery mean binocular UDVA did not differ from the six-month follow-up. All patients achieved binocular UNVA of
0.0 at both follow-ups. Mean binocular UIVA improved significantly from 0.06 to 0.01
(p<0.027), 6 months after surgery. All patients had very function at good visual all distances and were totally spectacle independent. CS under various conditions was within normal age-matched limits at both follow-ups. For some spatial frequencies six months postoperative results were significantly better than for the 3 months follow-up (p<0.05). Stereoscopic vision was normal. A low degree of glare/halo was detected in 75% of subjects. Overall patient satisfaction was very high (9.6/10).
There were no postoperative complications. The investigators concluded mixing and matching multifocal IOLs in selected cataract patients provides an excellent visual outcome, a high level of patient satisfaction and spectacle-free visual function. A period of neuroadaptation lasting at least six months is necessary to obtain better visual function results.
Altaie et al (2011) evaluated the efficacy, safety, and predictability of apodized, diffractive multifocal IOLs following phacoemulsification for cataract or clear lens extraction in a prospective, observational study of consecutive patients undergoing cataract or clear lens extraction (CLE) with insertion of the AcrySof Natural ReSTOR
IOL (SN60D3). Assessment included: manifest/cycloplegic refraction, corneal topography, biometry (Zeiss Humphrey IOLmaster), monocular and binocular uncorrected (UCVA) and best spectacle corrected (BCVA) distance and near visual acuity. Main outcome measures were visual acuity, spectacle dependence. 363 eyes of 203 patients underwent surgery (54.8% cataract, 45.2% CLE). Mean preoperative BCVA 0.30LogMAR, (6/12) [cataract] and 0.0LogMAR, (6/6) [CLE]. 161
(98.2%) of the CLE group were hyperopic and presbyopic (mean SEQ +4.25 ±
3.5D). Post-operatively UCVA was ≥6/12 in 96.5% of eyes (51.9 % ≥ 6/6) and ≥N5 in 95% of eyes. At six months 97.2% of the eyes were ≤1.00 D and 182 (91.4%)
[cataract] and 137 (83.5%) [CLE] eyes ≤0.50 D of target SEQ. 81.9% (n = 168) reported spectacle independence. 10.2% reported minor halos or other visual phenomena. No subjects required IOL exchange. Safety index at 6 months was 2.5 and 1.17 for cataract and CLE respectively. Investigators concluded the apodized, diffractive multifocal IOL predictably provided excellent near UCVA and good distance
UCVA following cataract and CLE surgery with a high rate of spectacle independence.
A minority of subjects note halos and other visual phenomena that may be related to
IOL design.
Accommodating Intraocular Lens Mar 16 6

Astigmatism-correcting intraocular lenses (IOLs), also known as toric IOLs provide correction or reduction of pre-existing astigmatism by incorporating a special curvature into the IOL. Prior to the advent of toric IOLs, pre-existing astigmatism could only be corrected by making limbal relaxing incisions into the cornea during cataract surgery to change its curvature, or by wearing astigmatism correcting eyeglasses after surgery.
Other recent technological advancements to intraocular lens development include the development of aspheric lenses, toric lenses and ultraviolet absorbing lenses. Several of these features may be applied to either monofocal or multifocal lenses, and in some cases, to accommodating IOLs. Aspheric lenses are slightly flatter and improve contrast sensitivity, decrease halos and improve optical quality, such as night driving performance. Toric lenses decrease eyeglass dependence due to astigmatism
(American Academy of Ophthalmology, 2006). Ultraviolet (UV) light absorbing lenses are made out of special materials that absorb UV and blue light, which are intended to protect the retina from the harmful effects of UV light.
In a 2002 study by Till, eighty-one patients had cataract surgery and implantation of an astigmatism-correcting IOL. After a mean follow-up of 23 weeks, an estimated
20% of the patients with astigmatism achieved good vision and reduced their need for distance glasses. Mendicute and colleagues (2008) evaluated the results of astigmatism-correcting IOL implantation following cataract surgery in individuals with preexisting astigmatism. They studied 30 eyes of 15 patients. The eyes in this study had a 70% reduction in astigmatism after astigmatism correcting IOL implantation.
However, the authors also concluded "Further studies with larger samples and longer follow-up should continue to evaluate the efficacy and safety of this IOL in cataract surgery." At this time, there is insufficient evidence from the available peer-reviewed literature to conclude that astigmatism-correcting IOLs are superior to the use of monofocal IOLs in conjunction with conventional eyewear.
Published data supporting accommodating intraocular lens technology continues to be limited. Study population numbers have been low with short-term results. There lacks sufficient evidence in the published, peer-reviewed literature to support longterm patient outcomes regarding safety and improved visual acuity. At the present time, it is unclear if the accommodating technology is superior to monofocal or multifocal intraocular lens (IOLs).
Based on a review of the current evidence, the National Institute of Health and
Clinical Excellence (NICE) issued guidance (2007) on implantation of accommodating intraocular lenses noting that accommodating lenses are at a relatively early stage of development and the technology is evolving. They report the current evidence suggests that there is evidence of short-term efficacy in correcting visual acuity, however, there is inadequate evidence that the procedure achieves accommodation. They reported no major safety concerns associated with the implantation of accommodating lenses for cataract.
Crystalens is a single-focus posterior chamber accommodating intraocular lens (IOL) composed of a solid silicon called Biosil. It was developed to address the loss of intermediate and near focusing ability after cataract surgery. The design element that makes Crystalens the state-of-the-art replacement lens are "hinges" which are designed to allow the lens to move, or accommodate, to focus on objects near, far and all distances in-between seamlessly, thus functioning more like the eye's natural
Accommodating Intraocular Lens Mar 16 7

lens. This device was shown to successfully restore 20/40 vision, or better, far away vision and near point vision in approximately 88.4% of patients in a clinical study, compared to 35.9% of patients who were implanted with a standard IOL. During clinical trials, the adverse events experienced were minimal and included persistent iritis (<1.0%), persistent cystoid macular edema (<1.0%), and cumulative cystoid macular edema (3.7%).
In the clinical studies with 324 patients over the age of 50, 100% could see images at intermediate distances (24"-36'), 98.4% could read print the size of the stock quotes in the newspaper or phone numbers in the telephone book and 98.4% could see distant objects all without glasses. 100% could see well enough without their glasses to pass their driver's test. It was also shown in the clinical studies that significantly more patients implanted with a crystalens (88.4%) could see better at all distances than patients implanted with a standard IOL (35.9%).
At this point, the FDA has approved the Crystalens for the treatment of presbyopia or loss of focus flexibility in cataract patients, although they may be implanted in patients without cataracts in what is considered an off-label use. Another IOL awaiting FDA approval, known as the ReStore lens from AMO, is a pseudoaccomodative lens that gives simultaneous near and distance vision. Additionally, the
Synchrony IOL from Visiogen is a dual-optic accommodative lens and is currently in overseas clinical trials. It is expected that the FDA will eventually approve the
Crystalens for people who don’t have cataracts, but wish to have their refractive errors corrected.
Even though preliminary studies have shown increased accommodative range and better near visual acuity than a control group with conventional IOLs, further research is necessary to confirm these results in masked, randomized, prospective studies and to confirm further the accommodative power of this group of new IOLs.
October 12, 2004
April 18, 2006
March 2007
April 2008
April 2010
April 2011
March 2012
March 2013
March 2014
March 2015
Medical Advisory Council
Update with no changes
Code updates
Update with no changes
Update with no changes
Update with Medicare table and added toric lenses
Update – no revisions
Update – no revisions. Codes updated.
Update – no revision
Review to consider member buy up
May 2015
March 2016
Added option for member buy up to premium lenses
Update – no revision. Codes updated.
1.
Philippine Academy of Ophthalmology. Clinical practice guideline for the management of cataract among adults. Philippines: Philippine Academy of
Ophthalmology; 2001.
2.
American Academy of Ophthalmology (AAO), Anterior Segment Panel. Cataract in the adult eye. San Francisco (CA): American Academy of Ophthalmology (AAO);
2001. Update 2011. Available at: http://one.aao.org/preferred-practicepattern/cataract-in-adult-eye-ppp--october-2011
3.
National Institute of Health and Clinical Excellence (NICE) Implantation of accommodating intraocular lenses for cataract. Feb 2007.
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Lipson MJ. Overview of contact lenses. UpToDate. September 11, 2015.
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Tomás-Juana J, Murueta-Goyena LA. Axial movement of the dual-optic accommodating intraocular lens for the correction of the presbyopia: Optical performance and clinical outcomes. J Optom. 2015 Apr-Jun; 8(2): 67–76. doi:
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Ang R, Martinez G, Cruz E, et al. Prospective evaluation of visual outcomes with three presbyopia-correcting intraocular lenses following cataract surgery. Clin
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Surg. 2013 Jan;39(1):48-55
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Dhital A, Spalton DJ, Gala KB. Comparison of near vision, intraocular lens movement, and depth of focus with accommodating and monofocal intraocular
4.
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Zamora-Alejo KV, Moore SP, Parker DG, et al. Objective accommodation measurement of the Crystalens HD compared to monofocal intraocular lenses. J
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Using Apodized, Diffractive Multifocal Intraocular lenses Following
Phacoemulsification for Cataract or Clear Lens Extraction. Clin Experiment
Ophthalmol. 2011 Aug 22. doi: 10.1111/j.1442-9071.2011.02671.x
2.
Lichtinger A, Rootman DS. Intraocular lenses for presbyopia correction: past,
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present, and future. Curr Opin Ophthalmol. 2012 Jan;23(1):40-6
Lubiński W, Podboraczyńska-Jodko K, Gronkowska-Serafin J, Karczewicz D.
Visual outcomes three and six months after implantation of diffractive and refractive multifocal IOL combinations. Klin Oczna. 2011;113(7-9):209-15.
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Swiątek B, Michalska-Małecka K, Dorecka M, et al. Results of the AcrySof Toric intraocular lenses implantation. Med Sci Monit. 2012 Jan;18(1):PI1-4.
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Bauer NJ, et al. Astigmatism management in cataract surgery with AcrySof toric intraocular lens. J Cataract Refract Surg 2008 Sep;34(9):1483-8.
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Horn JF. Status of toric intraocular lenses. Curr Opin Ophthalmol 2007
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Jampaulo M, et al. Long-term Starr toric intraocular lens rotational stability. Am J
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Mendicute J, et al. Toric intraocular lens versus opposite clear corneal incisions to correct astigmatism in eyes having cataract surgery. J Cataract Refract Surg
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Souza CE, Muccioli C, Soriano ES, Chalita MR, Oliveira F, Freitas LL, Meire LP,
Tamaki C, Belfort R Jr. Visual performance of AcrySof ReSTOR apodized
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6.
diffractive IOL: a prospective comparative trial. Am J Ophthalmol. 2006
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Harman FE, Maling S, Kampougeris G, Langan L, Khan I, Lee N, Bloom PA.
Comparing the 1CU accommodative, multifocal, and monofocal intraocular lenses: a randomized trial. Ophthalmology. 2008 Jun;115(6):993-1001.
7.
Gierek-Ciaciura S, Cwalina L, Bednarski L, Mrukwa-Kominek E. A comparative clinical study of the visual results between three types of multifocal lenses.
Graefes Arch Clin Exp Ophthalmol. 2010;248(1):133-140
8.
Marshall J, Cionni RJ, Davison J, et al. Clinical results of the blue-light filtering
AcrySof Natural foldable acrylic intraocular lens. J Cataract Refract Surg.
9.
2005;31(12):2319-2323.
Mendicute J, Irigoyen C, Aramberri J, et al. Foldable toric intraocular lens for astigmatism correction in cataract patients. J Cataract Refract Surg. 2008;
34(4):601-607
10.
Till JS, Yoder PR Jr, Wilcox TK, Spielman JL. Toric intraocular lens implantation:
100 consecutive cases. J Cataract Refract Surg. 2002; 28(2):295-301.
1.
Martínez Palmer A, Gómez Faiña P, España Albelda A, et al. Visual function with bilateral implantation of monofocal and multifocal intraocular lenses: A prospective, randomized, controlled clinical trial. J Refract Surg. 2008;24(3):257-
264.
2.
National Institute for Health and Clinical Excellence (NICE). Implantation of multifocal (non-accommodative) intraocular lenses during cataract surgery.
Interventional Procedure Guidance 264. London, UK: NICE; June 2008. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG264Guidance.pdf.
1.
Harman FE, Maling S, Kampougeris G, et al. Comparing the 1CU
Accommodative, Multifocal, and Monofocal Intraocular Lenses A Randomized
2.
Trial. Ophthalmology. 2007 Nov 19.
Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J
Ophthalmol. 2007 Sep;144(3):347-357
3.
Marchini G, Mora P, Pedrotti E, et al. Functional assessment of two different accommodative intraocular lenses compared with a monofocal intraocular lens.
Ophthalmology. 2007 Nov;114(11):2038-43. Epub 2007 Jun 6.
4.
Findl O, Leydolt C. Meta-analysis of accommodating intraocular lenses. J
Cataract Refract Surg. 2007 Mar;33(3):522-7
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Galand A. Accommodating intraocular lenses. Rev Med Liege. 2006
Apr;61(4):245-8
6.
Cumming JS, Colvard DM, Dell SJ, et al. Clinical evaluation of the Crystalens AT-
7.
9.
45 accommodating intraocular lens: results of the U.S. Food and Drug
Administration clinical trial. J Cataract Refract Surg. 2006 May;32(5):812-25.
Macsai MS, Padnick-Silver L, Fontes BM. Visual outcomes after accommodating intraocular lens implantation. J Cataract Refract Surg. 2006 Apr;32(4):628-33.
8.
Buratto L, Di Meglio G. Accommodative intraocular lenses: short-term visual results of two different lens types. Eur J Ophthalmol. 2006 Jan-Feb;16(1):33-9.
Dogru M, Honda R, Omoto M, et al. Early visual results with the 1CU accommodating intraocular lens. J Cataract Refract Surg. 2005 May;31(5):895-
902.
1.
U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Cataract in Adults: Management of
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Functional Impairment. Clinical Practice Guideline no. 4, AHCPR Publication no.
93-0544. Rockville, MD: Agency for Health Care Policy and Research, February
1993.
American Academy of Ophthalmology. Cataract in the adult eye. San Francisco,
CA: AAO; 1996.
3.
U.S. Department of Health and Human Services. Health Care Financing
Administration. Medicare Program; Limitations on Medicare Coverage of Cataract
Surgery. Federal Register. Friday, October 6, 1995; 60(194):52396-52403.
4.
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Bellevue, WA: McIntyre Eye Clinic and Surgical Center, February 1993.
Mamalis N, Crandall AS, Linebarger E, et al. Effect of intraocular lens size on posterior capsule opacification after phaecoemulsification. J Cataract Refract
Surg. 1995;21(1):99-102.
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Ophthalmology and Strabismus. J AAPOS. 1999;3(5):295-302.
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2001;54(1):23-29.
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Important Notice
General Purpose.
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are
Accommodating Intraocular Lens Mar 16 11

any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply.
Policy Limitation: Member’s Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. The Policies do not replace or amend the Member’s contract.
Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.
Reconstructive Surgery
CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery.
“Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function or
(2) To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.
Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.
Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.
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Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.
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