Eye care: 45% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2025 · Medical necessity · age 41–50 Contact lens · Eyes The physician reviewer found that a patient has requested authorization and coverage for multifocal intraocular lens.Clinical documentation reflects the presence of visually significant cataracts for which cataract extraction has been recommended. During the…

   The physician reviewer found that a patient has requested authorization and coverage for multifocal intraocular lens.Clinical documentation reflects the presence of visually significant cataracts for which cataract extraction has been recommended. During the consultation, the provider discussed the available intraocular lens implant options, including standard monofocal and multifocal lenses. Although multifocal intraocular lenses can decrease the need for glasses, they are not required for successful cataract surgery or for the correction of the visual impairment caused by nuclear sclerosis. The medical record supports that cataract extraction with a monofocal intraocular lens is the recommended and medically appropriate treatment. Monofocal intraocular lenses reliably restore vision impaired by cataracts, and most patients achieve excellent outcomes with glasses as needed for near or intermediate tasks. Many patients who receive multifocal intraocular lenses still require spectacles for certain activities, and some report visual side effects such as glare, halos, and reduced contrast sensitivity, particularly in dim light. When optic nerve or retinal concerns are present, multifocal lenses may be less appropriate due to their inherent reduction in contrast sensitivity, making monofocal lenses the safer and more effective option. Moreover, the requested multifocal intraocular lens is not medically necessary to protect life, to prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury, or necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Therefore, the requested multifocal intraocular lens is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45447

2. Overturned 2025 · Medical necessity · age 51–64 Corneal procedure · Eyes The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for (1) cornea transplant and/or (2) Gundersen flap surgery. Per the medical records, the patient has corneal disease. In this…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for (1) cornea transplant and/or (2) Gundersen flap surgery. Per the medical records, the patient has corneal disease. In this clinical setting, corneal transplant is not medically indicated due to poor visual potential and a high risk of graft failure. Given the poor prognosis, high surgical risk, and limited potential benefit, (1) cornea transplant is not medically necessary for the treatment of this patient. Gundersen conjunctival flap is appropriate for patients with chronic corneal surface disease, especially bullous keratopathy, that causes significant ocular discomfort but has no realistic potential for visual improvement. Given that a Gundersen flap is medically indicated as a palliative approach to manage pain and preserve ocular integrity in an eye with limited visual potential, (2) Gundersen flap surgery is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44957

3. Upheld 2025 · Medical necessity · age 65+ Other · Eyes The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for VEVYE (cyclosporine ophthalmic solution). Dry eye disease is a complex, multifactorial condition characterized by tear film…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for VEVYE (cyclosporine ophthalmic solution). Dry eye disease is a complex, multifactorial condition characterized by tear film instability, ocular surface inflammation, neurosensory dysfunction, and damage. It is a cyclical, multifactorial disease in which identifying and addressing the underlying cause is essential to breaking the cycle and restoring ocular surface homeostasis. This requires a personalized treatment plan. Therapeutic options include various strengths of cyclosporine, cholinergic agonists, semi fluorinated alkanes, corticosteroids, and procedural interventions such as intense pulsed light therapy or thermal pulsation. While cyclosporine at the requested dose has been shown to be safe and effective, it is clinically appropriate to initiate therapy with a lower-strength formulation. The decision regarding which therapy to initiate is at the discretion of the treating practitioner and should be based on individual patient needs and clinical presentation. In this case, the patient was given in-office samples of VEVYE. Although the patient reported symptomatic relief from the VEVYE samples provided, this alone does not align with the stepwise treatment approach outlined in standard clinical practice guidelines. Additionally, there is a lack of records detailing the clinical findings or objective measures of improvement associated with the use of VEVYE to support the patient's subjective report. All told, the requested VEVYE (cyclosporine ophthalmic solution) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44624

4. Overturned 2025 · Medical necessity · age 41–50 Other · Immune system Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Intense Pulse Light laser treatment. Findings: In this case, the patient has a history of cutaneous lupus erythematosus with concomitant melasma. The record…

   Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Intense Pulse Light laser treatment. Findings: In this case, the patient has a history of cutaneous lupus erythematosus with concomitant melasma. The record establishes that the patient has been treated with numerous topical medications, including hydroquinone 4% cream, tretinoin, and combinations thereof, without improvement of her condition. Thus, the requested Intense Pulse Light laser treatment is medically necessary for the treatment of this patient.The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Discoid lupus-induced skin changes, including melasma, can be considered an abnormal structure of the body as they are caused by disease. Further, the requested surgical procedure of intense pulsed light treatment is intended to create a normal appearance to the extent possible after the disfigurement caused by the patient’s cutaneous lupus erythematosus. In addition, it will provide more than minimal improvement in the appearance of the patient and thus would fall under the concept of medically necessary reconstructive surgery. For these reasons, the requested Intense Pulse Light laser treatment is medically necessary and reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-43530

5. Overturned 2025 · Experimental or investigational · age 51–64 Other · Eyes The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the placement of an artificial iris device to the right eye. There are multiple treatment options to address iris defects, such as tinted…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the placement of an artificial iris device to the right eye. There are multiple treatment options to address iris defects, such as tinted contact lenses, surgical pupilloplasty, and topical miotics. However, it is important to recognize that each case presents unique anatomical and functional challenges and that the appropriateness of these treatment modalities largely depends on the extent and severity of the iris damage, particularly when there is a significant loss of iris tissue. In this case, given the severity of the patient’s condition, the placement of the U.S. Food and Drug Administration (FDA)-approved iris prosthesis at issue offered both functional and cosmetic benefits that could not have been achieved with the alternative treatments mentioned. Therefore, the placement of an artificial iris device to the right eye was likely to have been more beneficial for treatment of the patient's condition than any available standard therapy. Findings: Three of the three reviewers found that the placement of an artificial iris device to the right eye at issue was likely to have been more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board-certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case EI25-45293

6. Upheld 2025 · Experimental or investigational · age 65+ Other · Eyes Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for NeoxFlo AMT (Amniotic Membrane Tissue). Although amniotic membrane grafts have been shown to be potentially beneficial in the treatment of moderate to severe dry…

   Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for NeoxFlo AMT (Amniotic Membrane Tissue). Although amniotic membrane grafts have been shown to be potentially beneficial in the treatment of moderate to severe dry eye, there is limited data available for the use of particulate human amniotic membrane tissue such as NeoxFlo. For this reason, the American Academy of Ophthalmology (AAO) lists amniotic membrane grafts as a treatment option for dry eye syndrome in step four of the staged management and treatment recommendations for dry eye syndrome. Along with amniotic membrane grafts, there are a number of other treatment recommendations that have not been documented for the patient in question. These treatment options include punctal occlusion, therapeutic contact lenses, moisture chamber goggles, and topical corticosteroids among others. Due to the variety of treatment options available for dry eye syndrome and the limited amount of data on the particulate human amniotic membrane, there is no evidence that NeoxFlo AMT will be more effective than other standard therapies in the treatment of this patient's dry eye syndrome. As such, NeoxFlo AMT is not likely to be more beneficial for the treatment of the patient's condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested services are not likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board-certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case EI25-43721

7. Upheld 2024 · Medical necessity · age 41–50 Other · Eyes Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel injections. The records indicate that this patient presents with recurrent chronic uveitis that has failed to improve despite treatment with…

   Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel injections. The records indicate that this patient presents with recurrent chronic uveitis that has failed to improve despite treatment with prednisolone eye drops and oral prednisone. The provider reports that the patient cannot tolerate higher doses of steroids due to the risk of increased intraocular pressure. The patient has requested treatment with Acthar Gel. The medical literature lacks support for the use of Acthar Gel in the treatment of patients with uveitis. Specifically, there is a paucity of prospective comparative cohort trials from multicenter and randomized protocols demonstrating the long-term safety and efficacy of Acthar Gel in the setting of uveitis. One study analyzed consensus recommendations from providers who treat patients with uveitis. The authors concluded that repository corticotropin injection therapy may be an appropriate treatment option for some patients with uveitis when other therapies are ineffective or intolerable. Another study found that adrenocorticotropic hormone gel plays a role in refractory and steroid-dependent cases and for patients who do not respond to or are unable to tolerate other immunomodulatory therapies. A third study included corticosteroids, methotrexate, mycophenolate, and tumor necrosis factor (TNF)-alpha biologic agents as evidence-based options for patients with uveitis. The authors do not discuss Acthar Gel as a recommended therapy supported by the medical literature. In this case, the records do not document that the patient has tried and failed, or has a contraindication to, the recommended therapies for patients with uveitis, including methotrexate, mycophenolate, or adalimumab. Therefore, the requested Acthar Gel injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN24-42256

8. Upheld 2024 · Medical necessity · age 11–20 Contact lens · Eyes Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for contact lenses. The records provided do not reflect evidence that the patient had a history of aniridia, aphakia, or keratoconus or an inability to…

   Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for contact lenses. The records provided do not reflect evidence that the patient had a history of aniridia, aphakia, or keratoconus or an inability to wear glasses due to a disease or condition to support an indication for contact lenses. The medical records do not provide documentation of keratometry readings or topography to assess the patient’s risk of keratoconus development. In addition, the chart documentation of visual acuity was measured with contact lenses only and does not measure whether the patient’s visual acuity with glasses is better or worse than visual acuity with contact lenses. For these reasons, the requested contact lenses are not medically necessary to prevent disease, disability, and other health conditions or their progression, to prolong life, to promote physical and mental health and efficiency, or to correct or ameliorate any physical or behavioral conditions. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in optometry and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN24-41515

9. Upheld 2024 · Medical necessity · age 51–64 Other · Eyes The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lipiflow. The records indicate that this patient presents with a history of bilateral dry eye syndrome, blepharitis, and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lipiflow. The records indicate that this patient presents with a history of bilateral dry eye syndrome, blepharitis, and Sjogren’s syndrome. The patient has undergone treatment with warm compresses as well as several medications, including Refresh and Cequa, which have not been substantially helpful. The patient’s provider has recommended treatment with LipiFlow. As noted in the medical literature, meibomian gland dysfunction is the most common underlying cause of dry eye disease. With regard to treatment with LipiFlow, the American Academy of Ophthalmology (AAO) states that there is a lack of evidence from independent randomized controlled trials demonstrating the efficacy of in-office procedures, such as LipiFlow, targeting the meibomian glands to treat dry eye syndrome. One study noted that “LipiFlow performs similarly to other commonly used dry eye disease treatments with regard to dry eye disease signs and symptoms.” The authors concluded that “Additional research with adequate masking, a standardized testing methodology, and a sample representative of the meibomian gland dysfunction population is therefore needed before any firm conclusions can be drawn regarding comparative benefits and harms.” On review of the current medical literature, there is a lack of support for treatment with LipiFlow to address this patient’s bilateral dry eye syndrome. Therefore, the requested LipiFlow is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN24-41063

10. Overturned 2023 · Experimental or investigational · age 65+ Other · Eyes The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for viscocanalostomy eye surgery. Ab-interno canaloplasty is a minimally invasive glaucoma procedure that has been demonstrated to decrease…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for viscocanalostomy eye surgery. Ab-interno canaloplasty is a minimally invasive glaucoma procedure that has been demonstrated to decrease eye intraocular pressure (IOP) with fewer postoperative complications compared to other procedures. Current data have reported that the effectiveness of canaloplasty has been shown to last up to five years. In one study, the authors found that canaloplasty “led to a significant 38% reduction in IOP value from the preoperative baseline to 18 months after the intervention. The number of medications decreased significantly by 89%”. Considering the studies reporting its high success rate, viscocanalostomy was an appropriate intervention for this patient as an alternative to other standard available treatment options for patients with mild primary open-angle glaucoma. Accordingly, the viscocanalostomy eye surgery was likely to be more beneficial for the treatment of the patient than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in ophthalmology and is actively practicing. Physician reviewer 2 is board certified in ophthalmology and is actively practicing. Physician reviewer 3 is board certified in ophthalmology and is actively practicing. The reviewers are experts in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition

    Case EI23-40162

11. Overturned 2022 · Medical necessity · age 51–64 Cataract surgery · Eyes The physician reviewer found that The patient has requested authorization and coverage for left eye cataract surgery with monofocal lens replacement. In this case, the patient’s visual acuity is noted as 20/25, with trace changes in the lens. However, testing…

    The physician reviewer found that The patient has requested authorization and coverage for left eye cataract surgery with monofocal lens replacement. In this case, the patient’s visual acuity is noted as 20/25, with trace changes in the lens. However, testing results show mild reduction of contrast sensitivity in the left eye and reduced visual acuity on brightness acuity testing. Overall, these results support the notion that the cataract in the left eye is contributing to the patient’s visual symptoms. Given the results of the glare testing, while the patient should be aware that the glare from the right eye will still be present when driving at night even after cataract surgery in the left eye, the requested service is medically indicated to improve the patient’s symptoms. Therefore, left eye cataract surgery with monofocal lens replacement is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned.

    Case MN22-37268

12. Overturned 2022 · Experimental or investigational · age 65+ Cataract surgery · Eyes The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has…

    The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has shown some issues with medication compliance. The provider has recommended intervention with the iStent procedure. On review of the current peer-reviewed medical literature, there is data that the iStent has been found to be a safe and effective treatment modality for this patient’s ocular hypertension with improvement in intraocular pressure (IOP). Malvankar-Mehta and colleagues noted that, “Both iStent implantation with concurrent phacoemulsification and phacoemulsification alone result in a significant decrease in IOP and topical glaucoma medications.” However, the authors concluded that, “In terms of both reductions, iStent with phacoemulsification significantly outperforms phacoemulsification alone.” Therefore, the requested iStent Trabecular Micro-Bypass Stent is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be overturned.

    Case EI22-37707