Insurance Coverage and Reimbursement Issues for Macular Hole Surgery

Joy Efron

Joy R. Efron, Ed.D.

Medicare, most health maintenance organizations, and most insurance companies still consider face-down equipment to be in the category of "comfort and convenience" and not "medically necessary." This is an extremely frustrating situation. I don't know how anyone can have a successful recovery without equipment.

I believe this is due to two factors:

  • Macular hole surgery is a low-incidence surgery and is not well-known or understood, as compared with surgeries such as hip replacements or knee replacements which come with much equipment, therapy, and assistance for the patient.
  • The face-down equipment is basically the same equipment used by massage therapists and thus has been interpreted as equipment for "comfort and convenience."

Immediately following each of my two vitrectomies, I was given a piece of soft foam (about 12" x 12" x 5") with a cutout for my eyes, nose, and mouth, and was told to go home and stay face-down. Unfortunately, this process is still typical in the United States and many other countries. Staying face-down would have been impossible for me had I not done research, bought some equipment, and rented other equipment.

I believe that insurance companies may cover the cost if your doctor will write that it is "medically necessary." This is especially critical for people with degenerative spinal conditions and other medical conditions, such as cardiac problems. Try very hard to get your doctor to state that the equipment and services are medically necessary. If your doctor does not write this statement, or if your request is denied, you can file an appeal. Several readers told me about being denied initially, but winning as a result of an appeal. It is encouraging to hear that some insurance companies are now covering the cost of this equipment.

One reader said this about filing an appeal:

I also had a six-month battle with my insurance company over the equipment. They denied the claim, stalled, and I appealed. When a nurse read my explanation, she approved the claim immediately and I got a check for a good chunk of the cost. I thought, what if there had been a true financial hardship? I probably spent more time arguing about it with them than it was worth, but I was convinced I was right and it should be covered.

Another reader said this about a woman who had macular hole surgery three times and did not use any face-down equipment because she did not know it existed:

For the first surgery, her daughter moved in with her. The patient kept her head down on a TV tray all day long (arms folded on the tray, with her forehead on her arms), while her daughter massaged her neck. At night, her daughter had set up pillows and foam with a breathing area and set the alarm every hour to check on her mother to make sure she was positioned correctly. The lady was miserable but recovered practically all of her vision.

A few years later, she developed a macular hole in the second eye. This time, a second daughter moved in but was not as "strict" with her mother. Consequently, the hole reopened a few months later and she had to have that eye operated on again. That time, the first daughter moved back in and repeated her strict regimen. She did recover her vision.

Financial Resources for Medication

If you're like many Americans, coping with the cost of medications can be burdensome, even with help from various health insurance plans. Some people cope by decreasing medication use below the recommended level; for example, by using glaucoma eye drops once a day instead of twice, or waiting to refill prescriptions. But not following your treatment regimen can lead to irreversible vision damage. If the cost of medication makes it difficult for you to follow the prescribed eye drop regimen, here are some resources that you may want to investigate further.

Medicare Drug Benefit

Medicare offers prescription drug coverage – known as Medicare Part D – to everyone with Medicare. To obtain Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered, and there are important enrollment deadlines. For more information, go to Medicare.gov and select "Drug Coverage (Part D)."

National Council on Aging

BenefitsCheckUp is a free, online service for people age 55 and older from the National Council on Aging. It provides information on a range of state and federal assistance programs, including medication assistance. The service is confidential and requires you to fill out a questionnaire online that takes about 15 minutes. Select "Find My Benefits" for a listing of programs for which you might qualify.

Eye Care America

Eye Care America is offered as a public service from the Foundation of the American Academy of Ophthalmology. It provides an online pharmaceutical directory that lists free or discount ophthalmic drugs available from major drug companies. Select "Medication Assistance" for more information.

NeedyMeds

NeedyMeds provides a clearinghouse of information on state and local assistance programs, as well as drug company discount prescription programs.

Updates in Macular Hole Treatment and Recovery

Also see Suggested Resources for more information about helpful products and organizations, as well as the author's contact information.

A Disclaimer

I was an educator of blind and visually impaired children for 42 years. Although I have read and researched a great deal and have had extensive discussions with retinal specialists, I am not an ophthalmologist or a medical doctor.

Reviewed by Mrinali Patel Gupta, M.D., VisionAware Medical Consultant

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