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Medicare Administrator Restricts Kinds Of Eye Procedures It Will Pay For In The VI and PR


MIAMI – The Medicare administrator contracted to work in the Virgin Islands, Puerto Rico and Florida has reduced the number and kinds of eye procedures that will be paid for by the federal government.

First Coast Service Options, Inc. (FCSO) said today that four types of specific eye care procedures will no longer be covered in “Jurisdiction N” because these decisions can be made at their own discretion.

FCSO the Medicare Administrative Contractor (MAC) for Jurisdiction N (covering Florida, Puerto Rico, and the U.S. Virgin Islands), removed the Current Procedural Terminology (CPT) “0100T” (Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy) from the listing of codes in the Noncovered Services Local Coverage Determination (LCD) because they “are considered not medically necessary and therefore not covered.”

This change enables coverage of the Argus II implantation procedure for Medicare patients in Florida, Puerto Rico and the U.S. Virgin Islands only under certain conditions favorable to the company.

“The Argus II implantation procedure must meet all regulatory requirements, including the medically reasonable and necessary threshold, to qualify for coverage,” the company said.

FCSO said it has the right to take the action it did because the Centers for Medicare & Medical Services (CMS), a federal agency that runs the Medicare program, relies on a network of Medicare Administrative Contractors, or MACs, to administer and process Medicare Fee-for-Service claims across 12 regions or jurisdictions within the United States.

CMS also delegates the authority to MACs to make the coverage determinations for a given service, procedure or device in the absence of a national coverage policy, meaning the company can do as it pleases to improve its overall bottom line.

Currently five Medicare jurisdictions, including CGS (Ohio and Kentucky), Palmetto GBA (Virginia, (excluding Part B for Arlington and Fairfax counties), West Virginia, North Carolina and South Carolina), NGS (J6 — Minnesota, Illinois and Wisconsin), NGS (JK — Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont) and FCSO (Florida, Puerto Rico and the U.S. Virgin Islands) provide coverage of the Argus II only “when medically necessary.”

The company continues to work with other MACs and payers to restrict and reduce future coverage policies for the Argus II.

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The Author

John McCarthy

John McCarthy

John McCarthy is primarily known for his investigative reporting on the U.S. Virgin Islands. A series of reports beginning in the 1990's revealed that there was everything from coliform bacteria to Cryptosporidium in locally-bottled St. Croix drinking water, according to a then-unpublished University of the Virgin Islands sampling. Another report, following Hurricane Hugo in 1989, cited a Federal Emergency Management Agency (FEMA) confidential overview that said that over 40 percent of the U.S. Virgin Islands public lives below the poverty line. The Virgin Islands Free Press is the only Caribbean news source to regularly incorporate the findings of U.S. Freedom of Information Act requests. John's articles have appeared in the BVI Beacon, St. Croix Avis, San Juan Star and Virgin Islands Daily News. He is the former news director of WSVI-TV Channel 8 on St. Croix.

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