Optometrist’s Services

30.4 - Optometrist’s Services (Rev. 1, 10-01-03) B3-2020.25 Effective April 1, 1987, a doctor of optometry is considered a physician with respect to all services the optometrist is authorized to perform under State law or regulation. To be covered under Medicare, the services must be medically reasonable and necessary for the diagnosis or treatment of illness or injury, and must meet all applicable coverage requirements. See the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage,” for exclusions from coverage that apply to vision care services, and the Medicare Claims Processing Manual, Chapter 12, “Physician/Practitioner Billing,” for information dealing with payment for items and services furnished by optometrists. A. FDA Monitored Studies of Intraocular Lenses Special coverage rules apply to situations in which an ophthalmologist is involved in a Food and Drug Administration (FDA) monitored study of the safety and efficacy of an investigational Intraocular Lens (IOL). The investigation process for IOLs is unique in that there is a core period and an adjunct period. The core study is a traditional, well-controlled clinical investigation with full record keeping and reporting requirements. The adjunct study is essentially an extended distribution phase for lenses in which only limited safety data are compiled. Depending on the lens being evaluated, the adjunct study may be an extension of the core study or may be the only type of investigation to which the lens may be subject. All eye care services related to the investigation of the IOL must be provided by the investigator (i.e., the implanting ophthalmologist) or another practitioner (including a doctor of optometry) who provides services at the direction or under the supervision of the investigator and who has an agreement with the investigator that information on the patient is given to the investigator so that he or she may report on the patient to the IOL manufacturer. Eye care services furnished by anyone other than the investigator (or a practitioner who assists the investigator, as described in the preceding paragraph) are not covered during the period the IOL is being investigated, unless the services are not related to the investigation. B. Concurrent Care Where more than one practitioner furnishes concurrent care, services furnished to a beneficiary by both an ophthalmologist and another physician (including an optometrist) may be recognized for payment if it is determined that each practitioner’s services were reasonable and necessary. (See §30.E.)