|A position statement for when medical insurance should pay for Lasik.
Medical Insurance Coverage
Medical insurance plans have
many different provisions regarding payment for refractive surgery like
PRK and Lasik. As a general rule, refractive surgery is considered
cosmetic surgery and is not covered. Under certain conditions, medical
insurance plans will cover refractive surgery. Often the process of
attaining coverage is confusing for both the insurance plan and the
To assist patients and the medical
insurance industry, The Council for Refractive Surgery Quality Assurance has provided a list a parameters under which
we believe payment for refractive surgery is appropriate under a medical
insurance plan. You may wish to print this information and provide it
to your medical insurance plan.
Indications for Reimbursement
It is our opinion that absent
the following conditions, refractive surgery would be an elective substitute
for spectacles or contact lenses and should not be eligible for reimbursement
under a medical insurance program.
We generally believe that medical
insurance should provide reimbursement coverage for refractive surgery
only where contributing pathology is present. We define contributing
pathology as any one of the following:
- Refractive errors that
are induced by injury.
- Refractive errors that
are induced by surgery.
- Anisometropia greater than
- Myopia greater than 10
- Hyperopia greater than
- Astigmatism greater than
- Inability to utilize spectacles
due to physical limitation (allergy, deformity, etcetera) and inability to utilize contacts due to physical limitation
(dry eyes, allergy, chronic infections, lens intolerance, etcetera).
Contraindications for Reimbursement
In the event pathology exists
as defined above, restrictions on reimbursement for refractive surgery
should be implemented if any one of the following also exist:
- Patient is under 18 years
- Presence of disease that
may cause continued unusual refractive change.
- The primary purpose of
the procedure is not to correct pathology, i.e. cosmetic, occupational,
experimental, or investigative.
- Treatment of complications
resulting from previous procedures not normally covered by medical
- The use of a device not
approved by the Food and Drug Administration.
- Insufficient documentation
to substantiate the procedure.
This position statement was first put forward in April 1999.
Looking For Best Lasik Surgeon?
If you are ready to choose a doctor to be evaluated for conventional
or custom wavefront Lasik, Bladeless Lasik, PRK, or any refractive surgery procedure, we recommend you consider a doctor who has been evaluated and certified by the USAEyes nonprofit organization.
Locate a USAEyes Evaluated & Certified Lasik Doctor.
If this article did not fully answer your questions, use our
free Ask Lasik Expert patient forum.