How Much Does Cataract Surgery Cost and Is Cataract Surgery Covered By Insurance?

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How Much Does Cataract Surgery Cost?

It’s not uncommon for a patient to ask how much does cataract surgery cost, and is cataract surgery covered by Medicare or commercial insurance? Regarding insurance coverage, the brief answer is that yes, cataract surgery is covered by Medicare and commercial insurance. The quick answer is ‘it depends’ regarding cost, but about $3000 per eye is a reasonable ballpark figure for everything including the surgeon fee, facility fee, and anesthesia fee. However, it’s important to note that a patient would be financially responsible for this only if they have a high-deductible health plan; when I perform cataract surgery in Traverse City the typical patient out-of-pocket costs run anywhere from zero dollars to $100 – $200 based on a patient’s deductible, co-pays, and co-insurance. Bear in mind there are regional differences in cost across the United States, and this is just one perspective from an eye doctor in Traverse City, MI.

Does Medicare Cover Cataract Surgery?

Yes, cataract surgery is covered by Medicare and commercial insurance as a medically necessary procedure, granted that the patient meets certain criteria. While requirements vary, a patient needs to be symptomatic and express difficulty performing any number of activities of daily living. The most common symptoms from cataracts are constantly blurry or hazy vision, trouble driving at night from increased glare, and difficulty seeing in low light. Additionally, some insurances mandate that a cataract cause vision loss of a certain level to consider the surgery medically necessary.

Are All Cataract Surgery Lens Options Covered By Insurance?

No, Medicare and commercial insurance only cover what are called monofocal intraocular lenses (IOLs) for cataract surgery. Premium upgrades to advanced technology lenses must be paid for out-of-pocket by the patient, these include toric lenses (astigmatism-correcting) and multifocal and extended depth-of-focus (EDOF, the Symfony lens) lenses. See this page regarding the various lens options available when someone has cataract surgery.

Is Laser Cataract Surgery Covered By Medicare or Insurance?

No, Medicare and commercial insurance do not cover laser cataract surgery (femtosecond laser cataract surgery). The patient must pay for any associated charges out-of-pocket. This isn’t a concern in my practice because I don’t currently offer laser cataract surgery; the most current scientific studies have shown that there is no benefit to the patient’s final visual acuity compared to our current techniques. See this page to learn more about laser eye surgery.

The Details Regarding The Cost Of Cataract Surgery

If only there were a simple answer to this question. Every medical and surgical procedure is associated with a CPT code (Current Procedure Terminology, a system put forth by the AMA). The CPT code for cataract surgery is 66984, although 66982 is also a cataract surgery code used when the cataract surgery is ‘complex’, which can happen for any number of reasons.

When it comes to the cost of any medical or surgical procedure, every doctor, medical office, and hospital comes up with a price for any given CPT code. Think of this as the “sticker price”. Keep in mind that hardly anyone ever pays the “sticker price”. When doctors decide to be “in-network” with any insurance company, they accept and/or negotiate rates for various CPT codes. Also keep in mind that many surgery CPT codes and their associated charges include post-operative visits in that one cost.

As an example, the surgeon fee “sticker price” for cataract surgery may be $1500, but the surgeon has agreed to accept, say, $900 from Blue Cross Blue Shield (BCBS). In that case, for a patient with BCBS, the surgeon fee is $900. Now whether it is BCBS or the patient that pays that $900 depends on the actual BCBS plan and any relevant deductibles, co-insurance, and co-payments. In my experience, the average patient would usually have to pay about $150 of this $900 based on the most common plans, with BCBS paying the rest.

Confused yet? Well it gets more complicated, because the surgeon fee is only one charge associated with having surgery. There are also the facility fee (paid to the hospital or surgery center) and the anesthesia fee (paid to the anesthesiology practice).

At Potthoff Eye Care & Surgery we have real-time eligibility checking of insurance coverage and benefits, this allows us to give patients a very good idea of how much cost they would be responsible for if they elect to have cataract surgery in Traverse City.

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