Medicare Cataract Surgery Payment Criteria

Question: I understand that the Medicare guidance for cataract surgery is that your vision has decreased to 20/40 and can't be corrected by refraction. I have been diagnosed with cataracts although my visual acuity is 20/30 in one eye (corrected to 20/25 minus 3) and 20/25 in the other eye (corrected to 20/20 minus 1.) The test with bright lights to simulate night driving decreases the vision to 20/40 in one eye and 20/30 minus 2 in the other.)

I feel like my vision has deteriorated significantly and I do have difficulty driving at night, although the tests above indicate things aren't too bad yet. Do you know if Medicare will cover cataract surgery at this point or will they only cover it if/when things deteriorate further so I am equal to or worse than Medicare guidance?

I should note that in addition to the visual acuity issues I mentioned, I also have glaucoma. I understand that in some (not all) cases, removal of cataracts can have the side effect of lowering IOP. So this a second motivation for considering cataract surgery at this point.

Answer: From what you describe, with glare testing you have one eye with a Cataract that is only correctable to 20/40 vision. You can certainly have Cataract Surgery covered by Medicare as the glare testing demonstrates the appropriate compromise in that eye. The 20/30 eye is borderline at this time but one would expect it will follow the same pattern in a relatively short term. Further, when you discuss your the surgery with your Cataract Surgeon you may want to ask whether you might be a candidate for Endocyclophotocoagulation (ECP) which is a type of treatment for Glaucoma that can be performed at the same time as the Cataract Surgery.

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