Insurance & Cataract Surgery

Insurance will generally cover cataract surgery. It is general health insurance that covers it, rather than vision insurance. Both private insurance and Medicare will typically cover at least 80 percent of the expense.

The cost of the surgery totaled about $2,526 per eye, or $5,052 for both eyes in 2018. This is the cost without insurance, so you can expect insurance to offset the majority of that.

When Medicare coverage is used, some beneficiaries pay as little as $316. Without any insurance, the surgery can run as high as $6,000 per eye, depending on the complexity of the individual’s condition.

Most people depend on insurance to cover the cost of an eye operation, such as cataract surgery

What Is Usually Covered by Insurance?

To fully appreciate how insurance costs break down, it helps to see what exactly a policy covers. The following information covers the basics. What you’ll end up paying is dependent on the type of lens that is used, the surgical technique, the facility fee, and any required follow-up visits. 

You also have to consider copays when reviewing the overall cost. For example, a copayment represents an established insured amount the policyholder pays for a covered health service after they’ve paid the deductible. 

Let’s say that your insurance provider’s allowable costs for a doctor’s office visit is $100. After paying your deductible, you’re required to pay a co-pay of $20 for the visit. If you pay a higher premium, you’ll usually be assessed a lower copay.

Knowing this information can help you set aside money and determine your insurance coverage and medical costs for specific procedures.

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What Private Insurance Normally Covers

Private insurance for cataract surgery is often comprehensive, but it also varies depending on the policy. Let’s look at the primary costs involved.

Surgeon’s Fee

Normally, the surgery will cover the fee of the doctor. What you’ll pay, whether or not you’re insured, will depend on the surgeon’s experience and reputation. Naturally, if the surgeon is well-recognized and has proven successes, their fees will normally be higher.

Facility Fee

Because the surgery is performed on an outpatient basis, you’re normally charged a facility fee. This charge covers the use of the site where the surgery is performed.

Removal & Replacement

Your insurance will cover replacement of the clouded natural lens with an intraocular lens (IOL). Usually, insurance policies cover monofocal lenses. If you wish to have a multifocal lens inserted or another type of premium lens, you may have to pay the difference in cost out of pocket.

Pre-Operative & Post-Operative Costs

These expenses cover doctors’ visits and the costs associated with preparing for the surgery and follow-up care. Insurance may cover testing, checkups, and medications, such as eye drops or prescription medicines.

Insurance & Medicare Cover Costs for Medically Necessary Procedures

Again, keep in mind that what you’ll pay yourself will depend on your deductible and co-pays. You’ll have to analyze your policy to see the percentages your insurance company will reimburse for allowable expenses.

In addition, insurance companies will not pay for cataract surgery unless they deem it as medically necessary. This means that the cataract is affecting your ability to see to the point that you can no longer opt for vision correction, such as an eyeglass or contact lens upgrade. 

Generally, the first step of cataract treatment is to simply monitor its development. Insurance won’t cover the cost of cataract surgery until a doctor deems that it is time to proceed to surgery.

Medicare Coverage

You can cover your cataract surgery through Medicare Part B. This part of the Medicare plan covers the following:

• Pre-surgery appointments
• The surgery itself
• Monofocal lenses
• Post-surgery aftercare services
• Eyeglasses or contact lenses after the surgery

If you wish to choose more advanced or premium IOLs, you might look into signing up for MediGap, which may cover these costs.

What Factors Influence Surgery Costs?

Several factors can influence what you’ll end up paying for a cataract procedure and how much your insurance will cover.

Type of IOL

Again, insurance and Medicare will usually cover a monofocal IOL. This type of lens corrects the vision at one distance, while a multifocal lens allows you to see both far and near. 

More advanced lenses include presbyopia-correcting IOLs or toric IOLs, which are used to correct astigmatism. Therefore, if you wish to have one of these lenses inserted, you’ll have to pay the difference yourself.

Type of Procedure

A traditional surgery, such a phacoemulsification, costs less than laser surgery. The traditional approach reaps good results, so if your insurance pays for phacoemulsification, you will still usually experience a successful outcome.

Surgeon’s Fees

Again, the reputation and experience of a surgeon will also impact the cost.

Setting for the Surgery

Usually, an ambulatory surgery center is less expensive than if you opt for an outpatient procedure in the hospital. Lens and cataract surgery tops the list of ambulatory procedures.

Pre-Surgery & After-Surgery Care

The costs of doctors’ visits, testing, and medications before and after the surgery can affect what you’ll pay overall.

The above variables all influence what eye surgery will cost. However, the primary determination for what you’ll pay is how much your insurance covers.

Is Laser Surgery Covered by Medicare?

Although an original Medicare plan does not extend to routine optical care, it will cover cataract surgery, whether you opt for lasers or the traditional ultrasound technique of phacoemulsification.

Do Insurance Plans Cover Laser Procedures?

An insurance plan will cover laser surgery, provided it is considered medically necessary, or the patient requires the surgery because using other methods of vision correction (eyeglasses or contact lenses) are no longer feasible.

How Payments for Cataract Surgery Work

If people pay for cataract surgery without the benefit of insurance, they make direct out-of- pocket payments. Because most insurance providers and Medicare considers cataract surgery to be a “covered service,” you’ll only pay for the extras you want when it comes to out-of-pocket payments. 

Coding for Cataract Procedures

When medical procedures are necessary, certain CPT codes are indicated for billing purposes. Below are samples of codes for essential services.

• 66830: This code covers the removal of a secondary cataract (or posterior opacified lens capsule and anterior hyaloid – or horizontal section of the eyeball) with the corneo-scleral part.
• 66840: This code is added to bills where the lens material is aspirated and removed.
• 66850: This code is noted for phacoemulsification, including aspiration.
• 66852: This code involves a pars plana lensectomy, usually performed with vitrectomy to remove a cataract and then reshape the pupil before removing vitreous opacities. All of this is done in one procedure.
• 66920: This code designates the removal of the lens when the surgeon performs intracapsular surgery.
• 66982: This code covers extracapsular surgery and includes the insertion of an IOL that requires devices not normally used in regular cataract surgeries.
• 66984: This code represents, per Medicare, the cost of a routine cataract surgery unless an exclusion is noted.

To learn more about the codes used for billing purposes, it’s helpful to look over your insurance policy and its billing guidelines for designating codes. Doing so can help you determine and itemize the medical services related to the cost of your cataract procedure.

HCPCS Codes

HCPCS codes may also be used on bills covering cataract surgery. Some of these codes may signify certain IOL technologies. For example, the codes C1780, V2630, and V2631 all designate types of IOLs.

ICD-10 Codes

ICD-10 codes may also be used on medical bills to describe specific procedures. For example, 08DJ3ZZ pertains to a surgery that includes removal of the right lens using a percutaneous approach. 

You can get more details about the criteria set for ICD-10 codes by reviewing this fact sheet.

Prepare to Avoid Surprises

You’ll have a lot to think about when getting cataract surgery. To make sure you’re well informed, find out what surgery will work the best for you, given your personal needs and budget. 
Before you have surgery, speak with your insurance representative or Medicare provider to itemize and narrow down the costs. By taking these steps, you’ll experience a better outcome medically and financially.

References

1. A Cost-Benefit Analysis of 2018 Cataract Surgery in the United States (2019). Clinical Research in Ophthalmology.

2. How Much Does Cataract Surgery Cost? (June 2022). GoodRx Health.

3. Coinsurance vs. Copays: What’s the Difference? (February 2022). GoodRx Health.

4. Cataract Removal Surgery for Adults. (October 2022). Anthem Clinical UM Guidelines.

5. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. (February 2006). National Center for Biotechnology Information.

6. Pars Plana Lensectomy. (2020). ScienceDirect.

7. MIPS 2019—Cost: The Routine Cataract Surgery With IOL Implantation Measure. (January 2023). American Academy of Ophthalmology.