Policyholder Services

OMIC Modifies Refractive Guidelines

Ray Fontenot, VP Underwriting

OMIC adopted the following changes, effective immediately, to underwriting requirements for refractive lens exchange (RLE), phakic implants, and PRK.

1. OMIC modified the underwriting requirements regarding patient selection criteria for treatment of myopia with refractive lens exchange. Under the previous guidelines, patients had to be presbyopic, age 40 or older, and have at least 6 diopters and not more than 15 diopters of myopia. Recent articles from Europe present evidence that the risk of retinal detachment following RLE in high myopes may not be as high as originally thought. One study shows that when a PVD is present preoperatively, the risk of postoperative retinal detachment after RLE or cataract extraction in high myopes is not significantly higher than among a normal population. Another study demonstrated that intraocular lens surgery is not a risk factor for retinal detachment in highly myopic patients; the risk profiles for postoperative and idiopathic retinal detachment were identical. Although this data is not definitive, the company determined its maximum permissible degree of myopia could be increased. OMIC is not aware of any peer-reviewed studies that support a significant reduction in the minimum degree of myopia required for refractive lens exchange, but a slight reduction was approved. The new guidelines continue to require that patients be age 40 or older and presbyopic. However, RLE is now permitted for patients with 5 to 15 diopters of myopia, or above 15 diopters up to 20 diopters if a PVD is present.

2. OMIC reduced the minimum interval between primary RLE procedures and between primary phakic implant procedures from one week to five days. This shortened interval improves scheduling flexibility and patient convenience without significantly increasing risk. Most cases of postoperative endophthalmitis occur three to five days after intraocular surgery, and the five-day interval still allows sufficient healing time so that the surgeon can evaluate the vault of the lens, determine the accuracy of the IOL calculation, or evaluate the effectiveness of LRIs before proceeding with the second eye. Because they are elective intraocular procedures with increased risks and longer recovery periods than refractive surgery procedures, OMIC does not offer coverage for bilateral same-day RLE or phakic implants.

3. OMIC modified its underwriting requirements for coverage of bilateral simultaneous PRK to eliminate the requirement that patients meet all FDA guidelines with respect to age, astigmatism, and myopia, thereby permitting off-label procedures to be performed on both of a patient’s eyes on the same day.

Refractive procedures represent a heightened need for thorough underwriting analysis and loss prevention strategies. We’ve learned through years of defending these cases in both settlement negotiations and at trial, that a risk management-oriented approach to elective procedures is often essential to successful defense of potential claims. OMIC maintains prudent refractive surgery underwriting requirements, first and foremost, to help strengthen the defense of our insureds from future malpractice claims. We also feel that careful underwriting protects our company from increased exposure to losses and helps us to continue to offer coverage for these procedures without additional charge. For more than twenty years OMIC’s related claim experience has been significantly better than the multi-specialty insurance industry.

OMIC’s requirements, based on sensible medical practice and sound risk management principles, are developed by practicing refractive surgeons on OMIC’s Board and Committees and are reviewed on a regular basis as new data becomes available.

For more information on OMIC’s current refractive surgery resources, recommendations, and requirements go here.