CG-SURG-96 Intraocular Telescope

This policy addresses surgical implantation of an intraocular telescope (e.g., Implantable Miniature Telescope) to improve vision. It is medically necessary for monocular implantation in individuals age 65+ who show at least a 5-letter ETDRS improvement with an external telescope in the operative eye, agree to 2–4 preoperative low-vision training/assessment sessions and postoperative visual training, and have adequate peripheral vision in the fellow eye. It is not medically necessary when any of these criteria are not met.

"An intraocular telescope (for example, the Implantable Miniature Telescope) is consideredmedically necessaryfor monocular implantation to improve vision in individuals 65 years of age or older when..."

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