Eye Surgery or Treatment Guidelines
Current Effective Date:
Revised 01/97; 05/03; 02/08; 04/08; 03/09; 05/09; 12/09; 01/11; 12/14
An individual is Eligible for Vocational Rehabilitation (VR) Services when it has been determined that (a) person has a disability of blindness or a visual impairment which for that person results in a serious impediment to achievement of an employment outcome, (b) that person can reasonably be expected to benefit from VR services in terms of an employment outcome, and (c) that person requires VR services to prepare for, enter, engage in, or retain gainful employment. Even though a person has a visual disability, a thorough analysis shall be done in order to make a determination as to whether a disability exists.
Listed below are the specific guidelines which should be followed by VR personnel relating to the sponsorship of eye surgery and/or treatment.
1. Cataract Surgery will be provided for individuals with corrected vision of less than 20/50 in the better eye. Cataract surgery will be provided for one eye only, which will usually be the eye with less vision. Very rare exceptions may be approved by the State Consulting Ophthalmologist. Exceptions will require documentation of medical necessity for vocational purposes (e.g. failed eye exam for CDL). Posterior subcapsular cataract surgery will need to be approved by the State Consulting Ophthalmologist.
a. An individual has corrected vision 20/50 OD and 20/70 OS and decreased vision OS is due to a cataract. DSB VR Services will provide assistance for the left eye only, which will frequently result in the individual having up to 20/20 vision in that eye.
b. An individual has corrected vision of 20/30 OD and 20/70 OS with decreased vision due to cataracts. This individual would not be eligible for DSB VR assistance at this time.
2. Following cataract surgery without implant, one pair of permanent cataract glasses may be provided by the State Agency. If recommended, temporary cataract glasses may also be provided.
3. Aphakic contact lenses may be approved by the VR field staff. Recommendations for other types of contact lenses and regular glasses may be approved by the VR field staff if the person has been determined eligible for services.
4. Following cataract surgery, requests for UV-400 Lenses, Photogray Extra or Tint No. 1 may be approved by VR field staff. These should be approved only in appropriate instances of light sensitivity as indicated by the pathology.
Intraocular Lens Implant
1. Unilateral Primary and Secondary Intraocular Lens Implants
a. For an individual age 18 years and older, designated VR field staff may approve implants.
b. For individuals under age 18, requests shall be reviewed by the Agency’s State Consulting Ophthalmologist.
2. Bilateral Primary and Secondary Intraocular Lens Implants
a. Implants may be approved by designated VR field staff under the following conditions:
(1.) The individual is 18 years of age or older, and
(2.) The individual has had successful intraocular lens surgery on the first eye and a minimum time frame of three weeks has elapsed between the first and second implantation. If less time is required for vocational reasons, designated VR field staff may approve.
b. All other requests shall be reviewed by the Agency’s State Consulting Ophthalmologist.
3. All specialized multi-focal and/or light filtering intraocular lens requests (for example: Toric, ReZoom, ReSTOR, and Crystalens) may be reviewed by the State Supervising Ophthalmologist.
All eye reports on which laser therapy has been recommended will be submitted to the Agency’s State Consulting Ophthalmologist for review, except for the following exclusions, which may be approved by the designated VR field staff:
1. Laser therapy for diabetic retinopathy if the eye report states that the retinopathy is proliferative, pre-proliferative, or exudative, or diabetic maculopathy.
2. Prophylactic photocoagulation for retinal horseshoe tears.
3. Photocoagulation for sickle-cell proliferative retinopathy.
4. Photocoagulation for macular edema.
5. YAG laser for posterior capsulotomy (less than 20/40 vision). All YAG procedures must be staffed and approved by the area supervisors. If questions arise, requested procedure can be staffed with State Supervising Ophthalmologist.
7. Laser trabeculoplasty if the doctor states that glaucoma is uncontrolled on maximum tolerated medication.
SPECIAL NOTE: In most cases, requests for photocoagulation for background retinopathy will not be approved. In all cases where it is recommended, the Agency’s State Consulting Ophthalmologist shall review the request and determine if it is approvable.
1. Requests for Radial Keratotomy will not be approved under any circumstances.
2. Requests for refractive surgical or laser procedures shall be submitted to the Agency’s State Consulting Ophthalmologist for review and would be considered only in very unusual circumstances.
3. Integrated Orbital Implant approved by the FDA in 1989—The literature describes this as follows:
“This implant is made of a unique material called porous hydroxyapatite. Hydroxyapatite is a form of calcium phosphate which is the same mineral that forms the hard portion of normal human bone. This is a naturally occurring substance in the body. The hydroxyapatite used for the implant is porous, just like human bone, which allows the patient’s own blood vessels and tissues to grow into it. This causes the implant to become a ‘living’ portion of the body. Integration of the implant with the patient’s body is the reason this implant is called an integrated orbital implant. This integration is a unique characteristic of this type of implant and is not possible with the standard orbital implant. It is this integration and ingrowth of the patient’s own tissues into the implant that allows the implant to later be attached to the artificial eye to give the artificial eye natural movement in conjunction with the normal eye.”
All requests for the Hydroxyapatite Integrated Orbital Implant shall be submitted to the Agency’s State Consulting Ophthalmologist for review.
4. Complex visual aids (orthoptic services) shall be submitted to the Agency’s State Consulting Ophthalmologist for review.
5. Plastic surgery—Any ophthalmological procedure involving any type of plastic surgery shall be submitted to the Agency’s State Consulting Ophthalmologist for review.
6. Area and District Vocational Rehabilitation Supervisors should require that all complicated, very involved procedures be submitted to them for review prior to being approved. If the Area and District Vocational Rehabilitation Supervisors have questions about the procedure and feel that additional consultation is needed, they should submit the recommendation to the Agency’s State Consulting Ophthalmologist for review. Such procedures include but are not limited to:
a. Field approval for Optical Coherence Tomography (OCT), CPT Code 92134
OCT is scanning computerized ophthalmic diagnostic imaging with interpretation and report, and is unilateral. Area Vocational Rehabilitation Supervisors District Vocational Rehabilitation Supervisors, and Counselors-In-Charge (for VR) and Nurse Eye Care Consultants (NECC) for Medical Eye Care (MEC), can approve OCT requests:
1. For views of the retina and macula when macular edema is present or is suspected, or
2. When the OCT is done in conjunction with Avastin therapy and when Avastin therapy has previously been approved by the State Consulting Ophthalmologist.
All other requests shall be submitted for review by the Agency’s State Consulting Ophthalmologist. Prior approval is to be made whenever possible; however, post approval can be done when delaying the procedure could be harmful to the individual’s vision. OCT will not be approved for glaucoma alone without the presence of other qualifying conditions.
b. Biometry charges for Intraocular Lens (IOL) for cataract surgery, CPT Code 92136
Ophthalmic biometry by partial coherence interferometry with IOL power calculation done in conjunction with cataract surgery shall be paid once per eye only to the surgeon performing the cataract surgery. Invoices for payment of biometry of the IOL done by an Optometrist (OD) will not be approved for payment.
c. Heidelberg Retina Tomography (HRT), and GDX Nerve Fiber Analyzer Requests for Glaucoma, CPT Code 92133
At this time, the Agency shall not pay for HRT or GDX, which are tests being used for diagnosis of glaucoma. Current literature does not support the reliability of these tests to track the process of glaucoma. As literature is reviewed and reliability improves, approval will be reconsidered. At this time, the Agency would like to track the number of requests for these tests. Vocational Rehabilitation Counselors shall send a short email to Chief, Vocational Rehabilitation Field Services, and Nursing Eye Care Consultants shall send the same to Chief, Independent Living and Medical Eye Care Services for the next six months when a request is received for either of these procedures.
d. Costs of processing, preserving, and transporting tissue for corneal transplant, V code 2785
If the facility where the transplant is performed provides a copy of the paid invoice or receipt that documents the tissue ID number and the amount the facility paid to the eye bank for the costs of processing, preserving, and transporting tissue, the Agency will reimburse the facility for the full cost.
If the facility does not provide a copy of the paid invoice or receipt from the eye bank and the Agency is billed for the cost of processing, preserving and transporting tissue for corneal transplant, the Agency will pay 75% of the changes.
e. Payment for both fluorescein angiography, CPT 92235, and OCT, CPT, 92134
During one evaluation, the Agency will pay for either a fluorescein angiography or an OCT in the course of a retinal evaluation where macular edema is present or is suspected. However, in rare occasions, physicians may submit justification for the essential need for both tests. In such cases, these shall be submitted to the Agency’s State Consulting ophthalmologist for approval.
f. Vascular Endothelial Growth Factor (VEGF) and other Ocular Injections
Approval for Avastin, Kenalog and Macugen injections shall be approved by the Agency’s State Consulting Ophthalmologist. When submitting the request for approval, the request shall state how many injections the individual has had, the outcome of any previous injections, and the prognosis with additional injections, and the number of injections request. Certain VEGF drugs are not approved for sponsorship such as-Lucentis.
g. Glaucoma Filtering
All glaucoma filtering and SLT procedures must be approved through the State Consulting Ophthalmologist. These procedures will only be approved after the maximum tolerable use of medications.
h. Surgery that is considered Elective or Cosmetic
Surgery that is considered elective or cosmetic will not be approved at this time. Examples are strabismus surgery to correct appearance only, ptosis or pterygium corrective surgery unless the individual’s vision is seriously impaired. Any exception, such as conditions that need correcting due to requirements of the individual’s vocational goal, must be approved by the Chief consulting Ophthalmologist.
i. For unusual or complicated tests and treatments
Unusual or complicated tests and treatments such as treatment for tumors, cancer or orthopedic conditions, the medical recommendation and justification must come from the treating physician and be staffed and approved by the Chief of Rehabilitation Field Services. If there are additional questions or concerns about the proposed treatment, the consumer may be required to obtain a second opinion by another appropriate physician.
j. Procedures that are unusual or have questionable results in improving or stabilizing vision
These procedures will not be approved at this time.
7. Pricing of non-Medicaid services
a. Reimbursed at 75% of a provider’s usual and customary charges if there is not a Medicaid or a Medicare rate.
For questions or clarification on any of the policy contained in these manuals, please contact the local district office.