Medicare covers a YAG (Yttrium Aluminum Garnet) laser capsulotomy if your doctor deems it medically necessary. A YAG laser capsulotomy is needed following cataract surgery to correct blurred vision, or “secondary cataracts.” Like cataract surgery, this procedure is performed on an outpatient basis. There are many things to consider before you schedule your procedure, such as recovery time, surgery-related expenses, potential risks and complications, as well as scheduling follow-up visits with your provider.

How YAG Laser Capsulotomy Works

YAG stands for Yttrium Aluminum Garnet, which is the crystal used to generate the laser in this procedure. A YAG laser capsulotomy, or a posterior capsulotomy, is performed post-cataract surgery to correct blurred vision by making small openings in the posterior capsule to clear out a cloudy film. Although cataract surgery has a 98% success rate, approximately 20% of patients experience hazy vision months or years after, making a posterior capsulotomy necessary.

How Medicare Covers YAG Laser Capsulotomy

Since Medicare Part A primarily covers inpatient hospital services, most care related to a YAG laser capsulotomy will be covered under Medicare Part B, which covers outpatient medical care. Outpatient surgeries such as posterior capsulotomy or cataract surgery, specialists’ visits, and follow-ups are all subject to a $240 annual deductible, followed by a 20% coinsurance. Following cataract surgery, Part B will cover one pair of standard eyeglasses or a set of contact lenses free of charge.

Eligibility Criteria

A doctor must recommend that the procedure is medically necessary. Otherwise, Medicare will not approve or pay for the service.

Medicare Part D and YAG Laser Capsulotomy Coverage

While Part D will not pay for drugs received at an outpatient setting, it will help pay for prescription drugs such as eye drops, antibiotics, and other medications related to a YAG laser capsulotomy. You must enroll in a separate drug plan, as it is not included in Original Medicare.

Medigap and YAG Laser Capsulotomy Coverage

Medigap, also known as a Medicare Supplement, is secondary insurance that helps pay for costs not covered by Original Medicare, such as your Part B deductible, coinsurance, and copayments. Medigap enrollment isn’t automatic, so you must submit a separate application to obtain coverage and pay a separate premium.

Medicare Advantage (Part C) and YAG Laser Capsulotomy

Medicare Advantage plans, also known as Part C, are private insurance plans that replace Original Medicare. Most Medicare Advantage plans include Part D (prescription drug coverage) as well. Your costs for a YAG laser capsulotomy and related specialists’ visits under a Medicare Advantage plan depend on your plan’s specific cost-sharing schedule.

Since Medicare Advantage plans offer additional benefits beyond what Original Medicare covers, you may also have routine vision services like eye exams and glasses covered as well. Since benefits vary from plan to plan, it is important to carefully compare your options.

Advantages and Drawbacks of Medicare Advantage for Beneficiaries Undergoing YAG Laser Capsulotomy

Advantages

Comprehensive coverage: Your cost-sharing must be as good as or better than cost-sharing under Original Medicare.
Prescription drug coverage often included: Part D is often included at no additional cost. This can help you pay for prescriptions like eye drops after your surgery.
Coordinated care: Your primary care doctor will be able to refer you to a specialist within the network who accepts your insurance, making it easier for you to be seen.
Out-of-pocket maximum: This is a cap on your out-of-pocket responsibility for the year. Original Medicare does not have a limit on how much you can spend.

Drawbacks

Health network limitations: You may be limited to network doctors or pay extra to see out of network doctors, depending on your plan.
More complicated coverage terms: Medicare Advantage plans have prior authorization requirements above and beyond Original Medicare, and it can take time to get your surgery approved which in turn delays care.
Not compatible with Medigap: You cannot have both of these plans at the same time.

How Much YAG Laser Capsulotomy Costs with Medicare

The national average cost of a YAG laser capsulotomy is about $600-$860, depending on where the procedure is performed. Keep in mind that ambulatory surgical centers will usually have lower fees than a hospital’s outpatient department. After you have met your Part B deductible (which is $240 in the year 2024), Medicare will pay 80% of the cost, leaving you with a 20% coinsurance. You may expect to pay approximately $120-$170 out-of-pocket, however some additional fees may apply.

If you have a Medicare Advantage plan, your deductible, copayments, and coinsurance are determined by your plan carrier. Be sure to read your plan’s Evidence of Coverage for an in-depth guide on what you can expect to pay.

Putting It All Together

A YAG laser capsulotomy may be needed if you experience blurred vision any time after cataract surgery. Once a doctor has determined it is necessary, Medicare will approve the procedure. Expect to pay your Part B deductible (if you haven’t met it yet) and a 20% coinsurance afterwards. Original Medicare will cover follow up visits and other eye care related to your surgery, but routine eye care such as annual eye exams are not covered.

Frequently Asked Questions

Where you can receive this procedure depends on the type of coverage you have. If you have Original Medicare and/or a Medigap plan, you can see any provider and/or facility in the U.S. and its territories who accepts Original Medicare.

However, if you have a Medicare Advantage plan, you may be limited to using only network providers. Be sure to check with your plan provider for information on who you can see to receive a YAG laser capsulotomy.

As long as a doctor has determined that a YAG laser capsulotomy is necessary to correct a vision impairment, the procedure will be approved by Medicare. However, diabetic eye exams and other care related to chronic eye conditions are also covered by Medicare.

Follow-up treatments and post-procedure care that have been deemed medically necessary and approved by Medicare will be covered. Routine eye care such as annual eye exams for contacts or glasses will not be covered by Original Medicare.

Some of the most common risks involved with YAG Laser capsulotomy is elevated eye pressure (also called ocular hypertension), detached retina, and glaucoma. It is important to know that an increase in eye pressure can damage the optic nerve, and this will eventually turn glaucoma. Unfortunately, there are no warning signs to prevent glaucoma. Some symptoms of glaucoma include blurred vision, nausea, headaches, and eye pain.

Does Medicare Cover YAG Laser Capsulotomy?

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