Division Policy 8.05
Eye Medical Treatment
February 1, 1996
April 15, 2013
This policy will be reviewed annually and updated as needed.
To provide guidelines regarding eye medical treatment.
FS 413; Rehabilitation Act of 1973, as Amended
To ensure that Division of Blind Services (DBS) clients are offered the most current and safest eye medical treatment; DBS meets with eye medical consultants on a regular basis. The consultants offer both medical guidelines for eye medical treatment and services to be provided under a procedural code.
The following guidelines are to be used in providing eye medical treatment to DBS clients.
- Cataract and laser surgeries for diabetics DO NOT require medical consultant approval. However, for cataract surgery there must be documentation in the clients electronic case file verifying the client meets the requirements in policy 8.19 Cataract Surgery prior to approval being given. All other surgeries, including YAG Lasers, must be staffed with the medical consultant using DBS-005 and entered into the clients electronic case file
DBS will only sponsor approved surgeries. Clients sponsored through DBS should not be sent to a medical teaching facility when services may be provided in the home district. If clients are sent to a medical teaching facility, it should be approved in advance by the medical consultant and/or the district administrator.
- Laser photocoagulation for retinopathy produces a nearly monochromatic and coherent beam of radiation used to purposely burn tissues of the eye for various clinical purposes. While medical consultant approval is not required for this type of laser for diabetic retinopathy, if used for other forms of retinopathy (hypertensive, central serous, etc.) consultant approval is needed.
- YAG laser may be used to treat posterior capsulotomies regardless of the presence of the lens. YAG may also be used for iridotomy. Health Care Financing Administration considers the YAG to be covered under a 90-day follow-up period and not billable. DBS will follow the same procedure and only pay for YAGs if there are complications that warrant such payment. This should be cleared in advance with the medical consultants with DBS-005 completed, signed by the consultant and a case note entered into AWARE that is has been done.
- Laser trabeculoplasty generally does not need to be repeated after a one- year period. In the event that it does, another facility fee will be paid, unless the laser is performed in the doctors office, in which case DBS will not pay a facility fee.
- The only brain tumor operations that should be sponsored in full or in part by DBS are those that involve the visual system with a prognosis guarded to good with surgery. The prior approval of the bureau chief is needed to perform any tumor operation and documentation must be placed into the clients electronic case file.
- DBS should not pay an additional fee for pre-op requirements for surgeries that are performed by the ophthalmologist or an additional physician. If there are extenuating circumstances, the district administrator may approve payment for pre-op tests listed on the clients plan and documentation of this must be placed into clients electronic case file.
- Glaucoma tension checks sponsored by DBS will be limited to three visits per year for glaucoma suspects and to four visits per year for glaucoma patients, unless an eye medical consultant recommends more than this number. DBS will sponsor a glaucoma suspect for a year at which time the case must be re-evaluated. The frequency of visits requested by the doctor should be used to decide if cases remain open.
Avastin Injections will only be sponsored for a one year period. Comparable benefits will need to be pursued by counselor and client during this year. If comparable benefits have not been located by the end of the treatment year, the DA may request an exception from the Bureau Chief to continue treatment. If an exception is granted documentation in the clients electronic case file must indicate the length of time treatment will be continued and what efforts will be made to assist client in locating resources for this continued treatment.
- On-going medical treatment must be staffed at least every 6 months with the medical consultant to substantiate the need for ongoing care utilizing DBS-005, and must be staffed with the DA to update efforts towards locating benefits to cover these medical expenses. Documentation must be in the clients electronic case file.
DBS will not sponsor eye medical care beyond one year without approval from the Bureau Chief.
PROCEDURE WHEN CLIENT HAS MEDICARE OR OTHER INSURANCE:
- An authorization is written for the total DBS approved amount of the service(s). In the Special Description field of the authorization write the following: Clients insurance MUST be billed as primary with DBS as the secondary.
- Once the clients insurance has paid for their portion, the vendor will send DBS an invoice AND the insurance statement, indicating what was paid by insurance.
- DBS will only pay the difference between what the insurance covered and the DBS allowable amount. DBS will modify their authorization for this amount and cancel the balance.
All DBS staff should comply with these policies and procedures.
Original signed by Aleisa McKinlay, Director, April 15, 2013