MedicalNecessityGuide.org

MedicalNecessityGuide.org

LASIK - Medical Necessity Criteria

Criteria for documenting medical necessity of laser-assisted in situ keratomileusis (LASIK).

Contents:

  1. Is LASIK covered by insurance?
  2. When is LASIK medically necessary?
  3. Medical necessity criteria for LASIK
  4. Does Medicare or Medicaid cover LASIK surgery?
  5. Frequently asked questions
  6. Documentation to submit
  7. Health plan criteria for LASIK and other references

Is LASIK covered by insurance?

LASIK is usually not covered by insurance, particularly if it is being performed for simple errors of refraction. There are limited instances in which LASIK may be considered medically necessary, in which case the procedure may be covered by insurance.

When is LASIK medically necessary?

There are rare situations in which LASIK may be considered medically necessary. One is in patients who have had prior surgery for retinal detachment; another is in patients who have had a corneal transplant. In both cases, the patient must meet all of the medical necessity criteria for LASIK surgery.

Medical necessity criteria for LASIK

There are only two situations* in which laser-assisted in situ keratomileusis (LASIK) may be considered medically necessary.

In patients who have had prior cataract, corneal or scleral buckling surgery for retinal detachment, LASIK surgery on the same eye may be considered medically necessary if all of the following criteria are met:

  1. Symptoms due to either:
    • aniseikonia (different sizes of ocular images), or
    • anisometropia (difference in power of refraction)
  2. Inadequate functional vision with any of the following:
    • contact lenses
    • spectacles
    • contact lenses and spectacles
  3. Either:
    • The post-operative refractive error has changed by at least 3 diopters when compared to the preoperative refractive error; or
    • The degree of astigmatism is 3 diopters or greater.

In patients who have blurred or distorted vision following a corneal transplant for infection, keratoconus, or trauma, LASIK surgery on the same eye may be considered medically necessary if they meet all of the following criteria:

  1. Significant astigmatism of ≥ 3 diopters (a few health plans may require only a 2 diopter difference)
  2. Cannot function with glasses
  3. Contact lenses are intolerable
  4. Reasonable expectation based on testing that the patient will function better after LASIK surgery

Otherwise, LASIK is considered NOT medically necessary.

Specific situations in which LASIK is considered investigational and/or not medically necessary include:

  • Not medically necessary:
    • Treatment of myopia between -1.0 and -15.0 diopters because this can generally be corrected satisfactorily with eyeglasses or contact lenses
    • Hyperopia up to + 6.0 diopters with or without astigmatism up to 5 diopters
  • Investigational:
    • Treatment of myopia greater than -15.0 diopters
    • Treatment of hyperopia greater than + 6.0 diopters
    • Treatment of astigmatism greater than 5.0 diopters
    • Most other refractive errors, unless the medical necessity criteria above are met
  • For convenience purposes — to replace the need to wear eyeglasses and/or contact lenses

* Health insurance companies may consider only one of these situations medically necessary. Some health plans may even contractually exclude refractive surgery. Always verify coverage and the medical necessity criteria that applies to patient’s specific health plan.

Does Medicare or Medicaid cover LASIK surgery?

Generally, neither Medicare nor Medicaid will pay for LASIK or other refractive surgery.

Frequently asked questions

Can LASIK fix astigmatism?

Yes, LASIK can correct errors of refraction in low to moderate astigmatism.

Can LASIK fix short-sightedness?

Yes, LASIK is in fact one of the preferred methods for treating short-sightedness, also known as nearsightedness or myopia.

Can LASIK correct long-sightedness?

Yes, LASIK is a popular quick, low-risk method for treating long-sightedness, also known as farsightedness or hyperopia.

How much does LASIK cost?

Depending on who performs the surgery, where you get it done, the technology that is used, and the level of correction needed, a LASIK procedure can cost you $1,000 to $5,000 per eye in total.

Documentation to submit

These are the things you can prepare documentation of in order to support your statement that LASIK is medically necessary. Submit only those that apply.

Health plan criteria for LASIK and other references

  • Aetna Criteria for Corneal Remodeling 
  • Anthem Blue Cross Criteria for Refractive Surgery 
  • Health Net of California Criteria for Refractive Surgery 
  • HealthPartners Criteria for Eye Surgery – Refractive 
  • Idaho Medicaid Provider Handbook for Eye and Vision Services  
  • Mississippi Medicaid Vision Services 
  • Paramount Medical Policy on Refractive Surgery  
  • South Dakota Medicaid Optometric and Optical Services 
  • TRICARE Policy on LASIK Surgery 
  • Tufts Health Plan Medical Necessity Guidelines on Laser Vision Correction Surgery