"Lazy Eye" Strabismus Surgery Covered? Original Medicare/Med Supp

[newbie2001]

Just enrolled a T65 into Plan G. She presently has an ACA plan and was going to get the surgery done with that carrier but is wondering if she could possibly done with Medicare since with the Plan G it will be significantly less.

I called the Plan G carrier they told me yes they would, my upline said it would, the internet says yes/no. My understanding is as long as its considered "medically necessary" then its good to go. But does that mean the PCP sends it to Medicare and Medicare has to check yes or no?

I usually deal with advantage plans so this is new to me. I know Plan G does not need pre-auths but procedures still need to be approved by Medicare? So technically a pre-auth kinda?

I referenced Somarco's post here but its also mixed answers

Does Medicare Cover Strabismus Surgery?

Client has double vision caused by a "loose" eye muscle. Doc recommending strabismus surgery. The condition ("lazy eye") common in children. Less so in adults. In this case it was diagnosed 3 yrs ago (client is 70) and has progressively become worse. Prism glasses provide temporary relief as...

www.insurance-forums.com

 

[Millwood]

The surgeon performing the surgery will absolutely know if patient meets medicare guidelines for the surgical procedure.
If Medicare approves a penny Med Sup will pay their Part. Med Supp Companies don't approve or deny claims . It all is dependent on Medicare .
If Dr. tries to get patient to sign an ABN (Advance Benificiary Notice) then patient will know Doctor isn't sure Medicare will approve based on ICD codes. If patient signs that form they acknowledge it isn't a covered service and they are responsible for 100% of bill. And...... providers can not get patients to sign blanket ABN on every patient who walks in facility. It's illegal.

 

[newbie2001]

So what I’m hearing is tell the insured to talk to the surgeon performing the surgery and the PCP so we can be 100% sure it will be covered? This case was a referral from a very close financial advisor friend of mine so I really don’t want to steer the client wrong.

@Millwood

 

[somarco]

So what I’m hearing is tell the insured to talk to the surgeon performing the surgery and the PCP so we can be 100% sure it will be covered? This case was a referral from a very close financial advisor friend of mine so I really don’t want to steer the client wrong.

All the more reason to let the doc handle it.

You really don't want an E&O claim and have it denied because you were "practicing medicine". The way the doc codes the claim determines if the procedure is medically necessary.

Some eye surgery is cosmetic and not covered, while other procedures are corrective due to medical necessity.

 

[newbie2001]

All the more reason to let the doc handle it.

You really don't want an E&O claim and have it denied because you were "practicing medicine". The way the doc codes the claim determines if the procedure is medically necessary.

Some eye surgery is cosmetic and not covered, while other procedures are corrective due to medical necessity.

Thanks for the assistance guys. Passed it on to the client.

 

[Travis Price]

I disagree with the don't give claims information. I just tell them what they want to hear and remind them my name is Chris Westfall.