I agree that these tests are being covered for beneficiaries who are not high-risk. There are others as well that I have questioned in the past for this same type reasoning.
The question is still IF the test need to be done every year, less often or even at all for those of us who have no high risk classification. That's a job for the medical society - but then they need to be all onboard and the coding for these test needs to be customized for those that are at risk and those that are not at risk.
I am ONLY going to cover the glaucoma test here in my analysis but the same could be done for the macular degeneration testing.
CMS.gov - Medicare Coverage Determination for Glaucoma Screening
This seems to have been revised just last November (11/2024)
Note that it says that the beneficiaries medical records should indicate their high risk category by the requirements and it gives the diagnosis codes and both have the high risk definition.
You can make a statement or ask a question at the end of the article but from experience you may or may not get any reply. The U.S. Preventive Service Task Force is the pseudo-government agency in charge of doing the research on preventive testing and grade them - anything that has an "A" or"B" rating was used by the PPACA law to get these services with no out of pocket cost.
See the "Recommendation of Others" to show how this is somewhat controversial in when and how testing occurs for those who are NOT in the classification of high risk.
I could give you evidence of other type of procedures that are similar - medical necessity is sometimes a tricky area but the documentation of the high risk condition(s) is pretty much set in stone here but yes, many opthalmologist and optometrist get paid for this test even if the beneficiary believes they have no risk factor because it is all in the coding - who actually checks the documentation?
What code did the optometrist use in your case? You could ask him or her what risk group you fall into and if this is in your chart and how did he/she come to this conclusion. Most likely the code used is used for all beneficiaries - indicating they are all at some sort of risk.
This is the written guidance that are given to the providers from CMS.
CMS.gov - Medicare Learning Network - Education and Outreach - Medicare Vision Services
It does seem that all of these Medicare documents say the same thing - agreed?
Is Medicare paying for something that should not be covered? Be sure to duck when it hits the fan.
Seems the Diabetes Screening coverage has a lot of us in the descriptive profile of being hit by this disease - at risk.
So I am wondering if this rather board description puts many of us in this at risk category?