Page 251 - Medicare Benefit Policy Manual

Iris fixation lenses;
Irido-capsular fixation lenses; and
Posterior chamber lenses.

While FDA has approved many IOLs, it still considers some IOLs investigational. The
fact that they are covered under Medicare is an exception to the general policy not to
cover experimental or investigational items or services. The exception is made because
the Congress, recognizing the widespread use of IOLs, directed the FDA to study them
without interfering with availability to patients.

The A/B MAC (B) determines whether the item or service falls into the categories
described in the following section. If it determines the item or service does fall into one
of those categories, it makes payment following the applicable rules for such items and
services found elsewhere in this chapter. If the item or service does not fall into one of
the categories described, the A/B MAC (B) denies the claim.

Covered ASC surgical procedures are those surgical procedures that are identified by
CMS on an annually updated ASC listing. Some surgical procedures covered by
Medicare are not on the ASC list of covered surgical procedures.

Under the revised ASC payment system, Medicare makes facility payments to ASCs only
for the specific ASC covered surgical procedures and covered ancillary services that are
provided integral to a covered ASC surgical procedure.

See chapter 14, section 10 of Pub. 100-04, Medicare Claims Processing Manual for
examples of covered ASC services for which payment is included in the ASC payment
for a covered surgical procedure under 42CFR416.65.

There is a payment adjustment for insertion of an IOL approved as belonging to a class of
NTIOLs, for the 5-year period of time established for that class, as set forth at
42CFR416.200.

260.3 - Services Furnished in ASCs Which are Not ASC Facility
Services
(Rev. 1, 10-01-03)
B3-2265.3

A single payment is made to an ASC that encompasses all “facility services” furnished by
the ASC in connection with a covered procedure. However, a number of items and
services covered under Medicare may be furnished in an ASC which are not considered
facility services, and which the ASC payment does not include. These non-ASC services
are covered and paid for under the applicable provisions of Part B. In addition, the ASC
may be part of a medical complex that includes other entities, such as an independent
laboratory, supplier of durable medical equipment, or a physician’s office, which are
covered as separate entities under Part B. In general, an item or service separately