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I want to get RLE to avoid cataracts. Does insurance cover it?

By Joel Hunter, MD | 5/26/17 7:53 AM
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With health insurance in the news off and on these days, it seems fitting to talk about how it applies to Refractive Lens Exchange (RLE). Who knows if health insurance will disappear altogether into some massive single-payer system? Or will it become some kind of individualized system based on bartering? Regardless, the issue will still come up when people ask about RLE.

The “avoiding cataracts” argument

When listing out procedures paid for by Medicare each year, cataract surgery always stays in the top three. Since Medicare standards are what most insurance companies abide by for rules on coverage, it means cataracts are a large part of the discussion when it turns to insurance coverage for specific procedures. These rules on coverage are a big deal in the conversations we have every day in a refractive surgery practice. If you don’t work in an eye clinic, they’re a big deal in those conversations that you regret starting. The ones where you realize too late that you’ve started chatting with someone who talks about this kind of stuff for fun at dinner parties.

The reason most RLE patients have this question is understandable. We’re talking about fixing a cataract before it gets bad enough for an insurance company to call it an “official” cataract (which is pretty bad). Shouldn’t insurance pay something here? Cataracts are one of the few conditions every human will get at some point if they live long enough. It seems like it would make sense for health insurance to cover RLE, because you’re fixing the problem before it becomes dangerous. The recovery is also going to be quicker and associated with fewer complications. And in doing so, you’re avoiding years and years of spending money on fairly expensive pairs of glasses. To save a big build-up to an ultimate letdown of an answer, I’ll interrupt to say insurance coverage of RLE is rare. At the risk of sounding snarky, I’ll point out the problem with this line of reasoning is you’re thinking like a normal, rational human being. I’ve dealt with health insurance policy requirements and rule books for several years, and here’s my conclusion: the only way to not end up maddeningly frustrated with the current state of things is to give up on approaching this subject with any rationality.

Here’s an example: I once sat through a phone conversation between an insurance rep and a well trained neuro-ophthalmologist. (A neuro-ophthalmologist specializes in the neurology associated with vision). He implored with passion that a carotid angiogram with and without IV contrast was essential for a particular patient. The need for this test was to diagnose a condition that could leave the patient blind. He failed to get this test approved. Not only that, but he was educated, by a person reading a manual, on why he was incorrect about the test being helpful. Remember that scene at the end of Saving Private Ryan when we see Matt Damon’s face age into the elderly man’s face over the course of a few seconds? I saw that happen in real life that day. I learned the quickest way to the agony of defeat is starting a battle you can’t win. In these cases, the outcome was decided long before you ever thought about it.

RLE gives you the power to choose

RLE sits in this small category comprised of decisions that improve life and prevent decline. While health insurance is vital, these companies run on the idea that if it isn’t “broke,” don’t fix it. The rest of that idea is if it is “broke,” it has to become more broken until it’s broken enough to meet several criteria. Then you can fix it. To cut them some slack, for the vast majority of medicine, the idea of fixing something in the body before it’s dangerously broken is usually a bad idea. Preemptive hip replacements don’t exist for good reason. But RLE happens to be different in two significant ways. One, it can provide glasses-free vision before a cataract causes vision loss, and two, everyone will get those cataracts someday. I still hold out hope that insurance will see it this way someday too—but I don’t hold my breath.

In the end, the choice to go with what insurance will cover once a cataract develops isn’t unreasonable if you don’t mind glasses. More than that, it’s the reasonable choice if you can spend your money on something that will make you happier than not wearing glasses. For folks who’d like to not need reading glasses, or who’ve worn glasses for the past fifty years, RLE won’t be decided by a health insurance company. It’ll be decided by you. For you, having eyes that see near and far without glasses is a better choice than waiting for your insurance to give permission. You chose a battle you can win.

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These articles are brought to you by Hunter Vision. We help people in Orlando discover life after glasses and contacts.
 
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