Policyholder Services

Do I need an endorsement for refractive lens exchange (RLE) to be covered for lens exchange on a patient who has previously had cataract surgery?

Whether the lens exchange will be considered refractive lens exchange (RLE) or an extension of the original cataract surgery for coverage purposes will depend upon the purpose of the lens exchange and the timing of the procedure.  If the patient has recently undergone cataract surgery but is unhappy with the visual outcome (for example, because the correct IOL power was difficult to calculate, there was a refractive surprise, or the wrong lens was inserted), surgery to exchange the lens would be considered an extension of the original cataract procedure and would be covered under the standard policy without endorsement for RLE.  Conversely, if a patient’s vision changes in the years following cataract surgery and the patient desires correction for the change in presbyopia, myopia, or hyperopia, the procedure would be considered refractive lens exchange for coverage purposes. In this situation, Endorsement OMC132I would be required for coverage to apply. Similarly, if a patient had a standard monofocal IOL placed at the time of cataract surgery and subsequently decides they would prefer a toric, multifocal, or accommodating IOL in order to gain more independence from their glasses, the surgery to remove the standard lens and replace it with a toric or presbyopia-correcting lens would be deemed RLE for coverage purposes and would require the OMC132I endorsement.

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