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

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

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

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.