Femtosecond Laser Assisted Cataract Surgery Consent

Femtosecond Laser Assisted Cataract Surgery Consent
The femtosecond laser (FS laser) is a medical tool the eye surgeon may use to perform some of the steps of cataract surgery. The eye surgeon uses the laser instead of a surgical blade and other tools. The laser makes a cut in the cornea (the front window of the eye). It is also used to make a circular opening in the outer layer of the cataract. It can help break up the cataract.

The FS laser can also treat astigmatism during the cataract surgery. Astigmatism causes blurry vision. Normally, eyes are round (like a baseball). With astigmatism, the eye is long (like a football). Glasses can treat this. Or eye surgeons can treat astigmatism during cataract surgery by making a cut in the cornea to change its shape. This cut is called a relaxing incision.

You have to pay extra for a relaxing incision. Medicare and private insurance do not pay for this.

There may be more risk if the FS laser is used after refractive surgery. Refractive surgery is a procedure that makes you see better (improves your refraction) by changing the shape of the cornea, the clear front of the eye. The FS laser uses suction. If you have had a type of refractive surgery called LASIK, the suction could open up or move the flap. If you have had other refractive surgeries called AK or RK, the suction could open up the old wound. If the flap or the wound is opened up or moved, this could cause leaking, astigmatism, or scarring.

The use of the FS laser on patients who have had refractive surgery is considered “off-label.” This means that the U.S. Food and Drug Administration (FDA) approved the laser for cataract surgery on the eyes of patients who have not already had refractive surgery. When eye surgeons use the laser during cataract surgery on patients who have had refractive eye surgery, its use is considered “off-label”. Your visual outcome after surgery may not be as good if these problems happen.

Risks. As with all surgery and medical procedures, problems can happen. In addition to all the risks for cataract surgery, here are some common or serious risks for the FS laser.

The cornea could be scratched. You could have an infection, bleeding, damage to your eye, fluid leakage from the eye, or increased eye pressure.
More time may be needed to perform the surgery. You may need to be taken to two different locations or two different rooms to perform the surgery.
The cuts into the cornea and the cataract might be off-center, incomplete, or broken up. If this happens, the FS laser can be used again or the eye surgeon could use a blade to cut the cornea.

The sack containing the cataract might tear, allowing pieces of the cataract to move into the back of the eye. If this happens, you may need another surgery called a vitrectomy to remove the cataract pieces.

Consent.

By signing below, you consent (agree) that:

You read this informed consent form or someone read it to you.
You understand the information in this consent form.
The eye surgeon or staff offered you a copy of this form.
The eye surgeon or staff answered your questions about the FS laser.
I consent to:

Use of the FS laser for some of the steps of the cataract surgery operationUse of the FS laser to create a relaxing incision
On my:

Right EyeLeft Eye
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Advance Beneficiary Notice of Non-coverage (ABN)
A. Notifier: Ophthalmic Consultant of New York, PLLC
B. Patient Name

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C. Identification Number or Date of Birth of Patient

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NOTE: If Medicare doesn’t pay for D. LASIK below, you may have to pay. Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect Medicare may not pay for the D. LASIK below.

D. Laser-assisted cataract surgery
E. Reason Medicare May Not Pay: Medicare statutory exclusion, coverage policy limitation, or other restriction.
F. Estimated Cost $1800 per eye

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.

• Ask us any questions that you may have after you finish reading.

• Choose an option below about whether to receive the D. Laser-assisted cataract surgery listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.OPTION 2. I want the D. Femto assisted cataract surgery listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare will pay
H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.
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CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: altformatrequest@cms.hhs.gov

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (Exp. 03/2023) Form Approved OMB No. 0938-0566

Notice of Exclusion from Health Plan Benefits
You need to make a choice about having:

Laser-assisted cataract surgery

This service is not a covered benefit and consequently your health plan willnot pay fir it. When you receive a serice taht is not a covered benefit, you are responsible to pay for it.

The purpose of this notice is to help you make an infomed choice about whether or not you wan tto receive these items or services, knowing that you will have to pay for them yourself. Ask us to explain, if you do not understand why your helath care service plan will not pay.

Your doctor has recommended:

The use of a femtosecond laser in refractive cataract surgery for making arcuate corneal incisions.

You are responsible for all of the estimated fees associated with a non-covered service. The charge for the surgeon's and ASC facility fee is $1800.
Beneficiary Agreement. Accordingly, the undersigned accepts full financial responsibility for the non-covered services described above.

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Femtosecond Laser Assisted Cataract Surgery Consent

Advance Beneficiary Notice of Non-coverage (ABN)

Notice of Exclusion from Health Plan Benefits