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SECTION 300: SPECIAL SERVICES

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REVISED: 03/29/2012

I. EYE SURGERY GUIDELINES

A. Emergency Surgery and Treatment

Note: Effective April 1, 2009, prior approval for emergency treatment and surgery will only be approved by the State Consulting Ophthalmologist.

B. Cataract Surgery

1. Cataract surgery can be approved by the Nursing Eye Care Consultant on both eyes with a corrected vision of 20/50 or less in the first eye and 20/70 or worse in the second eye. If the cataract is the posterior subcapsular type, and the vision is better than 20/50, the request must be submitted to the State Consulting Ophthalmologist for review. Each case should be carefully evaluated by the Nursing Eye Care Consultant to assure proper justification prior to authorizing each surgery.

2. Prior approval must be obtained or reimbursement will not be authorized.

3. Following cataract surgery without implant, one pair of permanent cataract glasses may be provided by the Division, and approved by the Nursing Eye Care Consultant. If recommended, temporary cataract glasses may also be provided.

4. Following cataract surgery, requests for UV-400 Lenses, Photo gray Extra or No. 1 Tint or No. 2 Tint may be approved by the NECC. They should be approved only in appropriate instances of light sensitivity as indicated by the pathology.

C. Intraocular Lens Implant

1. Unilateral Primary and Secondary Intraocular Lens Implant

a. For recipients age 18 years of age or older, Area Nursing Eye Care Consultant may approve implant.

b. For recipients under 18 years of age, request must be reviewed by the Division's State Consulting Ophthalmologist.

2. Bilateral Primary and Secondary Intraocular Lens Implants

a. Implants may be approved by area Nursing Eye Care Consultant under the following conditions:

(1) The recipient is age 18 years of age or older , and

(2) The recipient 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.

b. All other requests must be reviewed by the Division's State Consulting Ophthalmologist.

3. Specialty Lenses- Effective 07/2009

a. All specialized multi-focal and/or light filtering intraocular lens requests (for example: Toric, Rezoom, ReSTOR, and Crystalens) must be reviewed by the State Supervising Ophthalmologist.

D. Reimbursement to Hospitals for Intraocular Lenses

1. Intraocular lenses that are provided along with inpatient hospital surgery will be included as part of the per diem payment. No invoices required.

2. IOL's that are provided with outpatient hospital surgery will be included as part of the RCC rate of payment. No invoice is required.

3. IOL's that are provided in free-standing surgical centers will continue to be paid at invoice cost.

4. Biometry charges for Intraocular Lens (IOL) for cataract surgery- Effective 04/01/2008

Ophthalmic biometry by partial coherence interferometry with IOP power calculations done in conjunctions with cataract surgery shall be paid once per eye only to the surgeon performing the cataract surgery. Invoices for payment of the biometry of the IOL done by the Optometrist (O. D.) will not be approved for payment.

II. AUTHORIZING DRUGS FOR INDIVIDUAL RECIPIENTS

The Nursing Eye Care Consultant may authorize eye medications or drugs for individual recipients who are not eligible for Medicare or do not have any other drug treatment plan. These drugs must have a direct or beneficial action on the eye and may only be authorized if the recipient has an eye condition which will progress without drug therapy.

The Nursing Eye Care Consultant (NECC) will authorize approval of eye medications in the generic form when available and brand names when unavailable in generic form for the treatment of glaucoma. The Nursing Eye Care Consultant may approve brand name medications, but will require a letter of medical necessity from the eye care provider annually. Only over-the-counter lubricant/anti-allergy eye drops will be approved. The need for eye medications must be documented on the physician's report of eye examination. The NECC will authorize for the drugs through the Electronic Services System. See Section 400, Part C for instructions on completing DSB-0511 and DSB-4020.

Note: If the recipient of services from the Medical Eye Care Program is eligible for Medicare, he/she is not eligible for prescription drugs through the Medical Eye Care Program. Medicare offers prescription drug coverage (Medicare D). If a Medicare recipient's Part D plan does not cover a particular drug, the recipient may talk with their provider about selecting a drug that is approved by their plan and/or appeal to their plan.

III. Contact Lenses

A. All requests for hard or soft contact lenses will require authorization prior to service. Submit requests to Chief, Independent Living & Medical Eye Care Program in State Office for forwarding to the State Consulting Ophthalmologist.

IV. Safety Glasses

The Division of Medical Assistance (Medicaid) only purchase prescription eyewear and thus they do not purchase safety glasses for children. If a Medicaid eligible child has only one "good eye" and he/she meets the eligibility requirements for the Medical Eye Care Program, the Nursing Eye Care Consultant may authorize the purchase of safety glasses when a recommendation from an optometrist or ophthalmologist is received. It is not necessary to document medicaid denial.

 

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