Q for MD: Charges for Tecnis aspheric monofocal IOL

[askadvice]

I am scheduled for cataract surgery, both eyes, and after doing some online research think the Tecnis aspherical monofocal IOL is my choice.  For this IOL my MD charges an additional fee of $620 per eye, over and above what Medicare pays. This is a 'professional' fee they tell me which they are allowed to charge for extra (refractory ?) measurements required for Tecnis, ReStor and ReZoom IOLs (per Medicare CMS Ruling 0501 (or 05/01?), but not needed for traditional lens implants  (I should state that I think my Ophthalmologist/surgeon has years of experience and seems to be highly regarded and has also published in his fields).  
When I asked on this Forum if this extra charge was normal procedure I was advised that there are NO additional measurements required for this Tecnis aspheric monofocal IOL and that there should not be an additional fee.   www.aao.org only lists 2 cataract/IOL surgeons in my area in Florida; I left voice mails with both, but no one bothered to return my calls, nor did a couple other eye MD offices that I called.  I am not trying to get out of paying if this is a normal and accepted extra charge, but this fee seems to be unusual and contradictory.  
Can an MD please clarify this for me?  
Also, would you advise to set these Tecnis IOLs for 'modified' monovision for better intermediate vision?
Thank you in advance.

[Nester11]

Thank you. I have been in contact with the insurance company the past couple weeks. The bills have finally been submitted today. After reading this thread though it looks like I should never had to pay this large fee upfront. I was hoping that doctor could bolster my case. Thank you again.

[CBCT]

Hi,
FYI, Doctors no longer respond on this site.

I suggest you call your insurance company to see if they cover that lens.  If the answer is yes, you should submit a reimbursement claim directly to the insurance company along with a copy of the doctor's original bill.   Good luck.

[Nester11]

Dr.  I recently had cataract surgery and had a Tecnis aspheric lens put in eye eye.  Model ZCB00.  I was asked to pay upfront 1200.00 for each of these and signed an ABN indicating I wanted my insurance to be billed and if they paid I would get reimbursed.  The doctor is dragging his feet to bill this lens to the insurance.  The code is Q1003. The doctor office is institing this is a premium lens that insurance will not pay for however research I am doing shows that they do pay for this.  It is not a multifocal lens.  I saw your posts here saying that there should not be an extra charge for this.  Can you explain this more to me.  What recourse do I have?  

[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

Wow, I'm glad I don't need cataract surgery in your part of Florida.  But I suppose that an (illegal) charge of $30 is better than paying $620.  

[askadvice]

Thank you for your information.  I was told that I needed surgery to have cataracts removed in both eyes; there was no mention of presbyopia.  When I called my MD's office and asked if this Tecnis lens was a multifocal IOL, I was told that it is an aspheric monofocal, that the doctor does not use the Tecnis multifocal (which I learned on this Forum is not available in the U.S. at present).  
I have now made an appointment with another eye MD/surgeon who I was told only charges an extra $30 for refractory measurements for this Tecnis lens.

[John C Hagan III, MD, FACS, FAAO]

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[cdn_glenn]

I looked up CMS Ruling 0501 and came up with this PDF:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm3927.pdf

I believe the intent of the additional charge is for a Presbyopia-Correcting IOL.

from the above document:

Presbyopia is a type of age-associated refractive error that results in progressive loss of the focusing power of the lens of the eye, causing difficulty seeing objects at near distance, or close-up. Presbyopia occurs as the natural lens of the eye becomes thicker and less flexible with age.
A single presbyopia-correcting IOL can provide what would otherwise be achieved by two separate items:
   • An implantable conventional IOL that restores far vision; and
   • Eyeglasses or contact lenses that correct for presbyopia.

The document gives examples of three lenses:
   • Crystalens™, manufactured by Eyeonics, Inc.
   • AcrySof RESTOR™, manufactured by Alcon Laboratories, Inc.
   • ReZoom™, manufactured by Advanced Medical Optics, Inc.

The Tecnis aspheric monofocal IOL is not considered a Presbyopia-Correcting IOL, as it only affects one zone ... usually distance.  Implanting monofocal IOLs to create monovision IMHO does not meet the criteria to charge for Presbyopia-Correcting IOL.  I am still wondering, though I don't think it is yet approved for use in the USA, that it is the Tecnis Multifocal lens being described.  Otherwise, I cannot see how the additional charge is warranted.

[askadvice]

Thank you, Dr. Hagan.   No, it is not a 'misunderstanding' on my part about the charges as I spoke several times with the person in charge of the technical aspects of pre-op (I am not sure of her title, only that she is the 'supervisor'), and she told me in no uncertain terms that they are allowed to charge this extra 'professional' fee for Tecnis, ReStor etc. (per 'CMS Ruling 0501' which she read to me) and that if I expect her to tell me that I won't have to pay this charge, that there is no chance she will do that!. Initially it was a 'charge for the lens', then it was for 'extra measurements' needed for this Tecnis lens.  When I called again (with newly learned info from the Forum that there are no extra measurements needed), the charge became a 'professional fee'.  I could tell from her voice that she was getting frustrated by my questioning this fee for the Tecnis aspheric monofocal lens.  
I would never have doubted this charge had I not been advised on this Forum on several occasions that there should be no extra charge for this lens.
Yes, JodieJ is a real asset to this Forum and I am very appreciative of her help.
Thank you again for your advice.

[John C Hagan III, MD, FACS, FAAO]

Thanks for the thanks. JodieJ adds a lot to these forums and we're very luck to have her.

I hope you merely mis-understood what the charges would be because charging extra over what Medicare allows is not only not allowed its illegal.

JCH MD

[askadvice]

Thanks again for your input.  Following your advice on Aug. 4, I looked at the Tecnis website and saw their video fairly early into my 'research', which in part was the reason why I decided on the the Tecnis aspheric monofocal IOLs.  I will get a second opinion and also discuss the 'blended vision'.
Your previous advice and Dr. Hagan's precise info today in regard to the allowable charges for this lens should surely save me $$$.  I really appreciate your help.

[askadvice]

Dr. Hagan, thank you so much.  I will definitely take your advice and get a second opinion before surgery.  Your reply also confirmed what I was sort of suspicious of - that this extra charge was not the norm.  
Thanks again - you made my day!

[JodieJ]

Isn't this forum great?  (You may have saved $1240.)

Dr. Hagan has stated elsewhere on this forum that "blended vision" with aspheric monofocal lenses would work well for many people.  The targets he suggested are -.25D (dominant eye) and -1.25D (non-dominant eye).  My friend who has a similar correction only wears drug store readers for seeing small print.  He can usually read restaurant menus without them.  You can learn more about the Tecnis monofocal IOL at www tecnisiol com.

I shouldn't criticize a "highly regarded" ophthalmologist, but his initial "top recommendation" for you of bilateral ReZooms was a red flag in my mind.  

[John C Hagan III, MD, FACS, FAAO]

I would advise that you NOT have cataract surgery without getting a second opinion from another surgeoon AND a more detailed explanation.

At present Medicare does NOT allow extra charge for tecnis aspheric monofocal IOLs. I know because this is what our large clinic uses.

Extra charges are only allowed for "Premium" IOLs which at present include Crystalens, ReStoR and ReZoom MULTIFOCAL IOLS.

I understand that Tecnis has developed an multifocal IOL but I am not sure it is available in the USA>

THUS you should NOT be charged extra for a tecnis monofical IOL.

JCH MD