PhilHealth solidifies standards for eye surgery claims

The Philippine Health Insurance Corporation (PhilHealth) has introduced a new policy to reinforce quality standards and improve patient outcomes for eye surgeries covered under the national health insurance program, particularly those involving pterygium excision and ocular surface reconstructive surgeries.

PhilHealth Circular No. 2025-0021, effective 15 November, outlines comprehensive clinical guidelines for the surgical removal of pterygium, a fibrovascular growth on the eye often referred to as “pugita sa mata” that can impair vision if untreated.

The new directive mandates strict quality control, requiring accredited facilities, qualified surgeons, and adherence to proper surgical and post-operative procedures.

“This is our way of ensuring that every PhilHealth member receives the highest standard of eye care,” said PhilHealth president and CEO Dr. Edwin Mercado, adding that the corporation continues to collaborate with specialists and strengthen monitoring mechanisms.

A key feature of the new policy is the implementation of a maximum claim limit per surgeon. This cap is designed to prevent overutilization and maintain patient safety. It excludes procedures done by residents-in-training at accredited institutions, thereby encouraging continuous training and expanding access to care in both public and private hospitals.

The policy was developed in consultation with the Philippine Academy of Ophthalmology and the Philippine Cornea Society. PhilHealth currently covers pterygium excision with graft and ocular surface reconstruction procedures for up to P59,085.

A study by the Philippine General Hospital estimated that 2 percent of new eye patients suffer from pterygium, with outdoor workers exposed to sunlight and dust identified as being at higher risk.

The initiative is seen as part of President Ferdinand Marcos Jr.’s health agenda aimed at lightening the burden of costly medical interventions while promoting quality-focused healthcare.