My plan covered my cataract surgery but not the lenses I actually needed-how do they get away with that?

Question

Melonie Wood · Accepted Answer

Insurance plans, including Medicare, typically cover the cost of standard monofocal intraocular lenses (IOLs) for cataract surgery, but they often don't cover the extra cost of more advanced lens options like toric, multifocal, or extended depth-of-focus (EDOF) lenses. This is because these advanced lenses offer additional features beyond basic vision correction and are considered "premium" upgrades.

Answered by Melonie Wood on April 12, 2025

Agent Licensed in FL & AL

Answered by Melonie Wood Medicare Insurance Agent

Lt Col Tim Brown · Answer

Medicare approves or not a procedure.  If they don’t approve it, it’s not going to be covered.  Your argument is with Medicare.  Call you plan for more information on the why it’s not covered.

Mitch Anderson · Answer

Medicare approves the surgery and lenses that are directly related to the medically necessary repair of the cataract. Unfortunately, Medicare (and subsequently your plan), does not consider advanced lenses used to correct conditions like astigmatism and nearsightedness as medically necessary, this is considered elective.

Answered by Mitch Anderson on May 6, 2025

Agent Licensed in MN, IA & WI

Answered by Mitch Anderson Medicare Insurance Agent

Steven Bleicher · Answer

These situations likely mean that you have a Medicare Advantage plan. If so, companies have the right to vary the regulations and in your case, cataracts are common and they are saving you money for the surgery, done weeks apart on both eyes. Not to be punny, but you have to treat your initial Medicare Agent interview with both eyes open. Don’t forget that the Supplement plan provides specific differences that you are going to need a number of years later than when you 1st turn 65! Do consider everything!

Answered by Steven Bleicher on April 12, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Yasmery Vargas · Answer

Cataract surgery is typically classified as a " medically necessary outpatient procedure." Because it is deemed a medically necessary procedure, it is covered under Medicare. Lenses, contacts, sunglasses, Bifocals used for vision improvement are usually subject to your vision benefit associated to your specific vision plan. I will add, there are critical illnesses in the eyes that exist where glasses are medically necessary. Refer to your benefits for specific.

Answered by Yasmery Vargas on May 15, 2025

Agent Licensed in PA

Answered by Yasmery Vargas Medicare Insurance Agent

Tammy Stoner · Answer

Medicare will cover most medically necessary lenses, but not premium or advanced lenses to enhance vision.

While this is frustrating, there are options to assist with coverage. One may choose to enroll in an advantage plan that offers additional coverage for vision. Also, a supplemental vision plan may help mitigate the additional cost for lenses, frames, or contacts.

Michael Crocker · Answer

Medicare typically covers the cost of the surgery itself, including the removal of the clouded lens and implantation of a a basic intraocular lens (IOL) only. If you or your doctor believes that a specialty lens is a medical necessity, you may file an appeal with Medicare (if you have original Medicare) or your Medicare Advantage plan (if you are on an MAPD).

Answered by Michael Crocker on March 29, 2025

Broker Licensed in SC

Answered by Michael Crocker Medicare Insurance Agent

Fred Manas · Answer

Many insurance plans cover the basic cost of cataract surgery and the standard monofocal intraocular lens (IOL) implant, but not all lens options are covered. Premium or advanced technology lenses, like toric lenses (for astigmatism) or multifocal lenses (for different vision needs at various distances), often require out-of-pocket payment. This is because these lenses offer additional benefits beyond the basic functionality of a standard monofocal lens. 
Elaboration:
Insurance Coverage:
Most health insurance plans (including Medicare) cover the cost of cataract surgery and the standard monofocal IOL, which helps correct vision for one distance. 
Premium Lens Options:
However, many insurance plans consider premium or advanced technology lenses, like toric lenses and multifocal lenses, as upgrades and don't fully cover their cost. 
Out-of-Pocket Costs:
If you choose a premium lens, you'll likely need to pay the difference between the covered cost of the standard lens and the price of the advanced lens out-of-pocket. 
Why the Difference?
The insurance industry often differentiates between the basic medical need of cataract surgery (which they cover) and the patient's choice of a specific lens technology (which may not be covered). 
Communicating with Your Insurance Provider:
It's essential to contact your insurance provider before your surgery to fully understand your plan's coverage for different lens options and potential out-of-pocket costs. 
Alternatives to Out-of-Pocket Costs:
Some plans might offer options like Medicare Advantage plans, which can provide additional coverage for premium lenses. You can also explore payment plans or financing options offered by eye clinics or surgeons.

Sam Silva · Answer

In most cases, Medicare covers cataract surgery, but it does not cover the cost of lenses if you choose premium intraocular lenses.

Standard lenses are covered by Medicare, meaning if you need a basic lens to restore vision, Medicare will usually pay for it.

Mary Salmon · Answer

Medicare covers cataract surgery, including the removal of the cataract and basic lenses. However, special lenses are considered elective and not covered by Medicare.

Rachael Metcalf · Answer

Original medicare does not cover that. But advantage plans cover it with a $0 copay.
So not sure what you are on....I am guessing a supplement?

Charles Borg · Answer

That’s unusual. The lens is usually covered, unless you want some sort of upgrade. Cataract surgery provides for a lens, but not special ones.

Tracy Brown · Answer

Well, that is partially true. Rumors are everywhere and it's frustrating, right?  People talk about having cataract surgery.  Medicare pays for the surgery itself... but then you’re left footing the bill for the lenses you need. Really? Most people can get the "Free" standard intraocular lens.  (Nothing is free if you have astigmatism).  Eye doctors will 'upsell' you saying you don't have to wear 'cheaters' to see up close afterward.  My personal experiences with my mother and first cousin, who both got the 'free' Medicare lenses, were very happy!  They also saved $5K-$7K per eye! Call MedWiseTrust. Ask about this when we meet on Zoom or in person. 

Original Medicare (Part B) does cover cataract surgery, including:

✅ Surgery to remove the cataract
✅ A standard intraocular lens (IOL)
✅ One pair of eyeglasses or contact lenses post-surgery
✅ Anesthesia, facility fees, and some follow-up care

❌ What’s not fully covered?
Premium or advanced lenses, like:  Toric lenses (for astigmatism) and multifocal or accommodating lenses (for seeing near & far). Anything beyond the basic mono-focal lens

Medicare considers those “elective” or not medically necessary—even if they would improve your quality of life dramatically.  So they “get away with it” because they only promise to restore basic vision, not necessarily your best vision.

What can you do?
Appeal – If your doctor documented a medical reason why a premium lens was necessary (not just preferred), you might have a case. (I have never seen anyone win an appeal)  Pay with a pre-Medicare FSA or HSA may be able to used toward the cost.

Andrew Norton · Answer

Typically the cataract surgery is covered by Medicare under Part B. Unless they are deemed Medically necessary, your lenses may only be covered on a separate vision plan.