PhilHealth tightens eye surgery standards

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

Pterygium, often referred to as “pugita sa mata,” is a fibrovascular growth on the eye that can impair vision if left untreated. In a study conducted by the Philippine General Hospital, an estimated 2 percent of new eye patients were found to have the condition, with a slight majority being women and almost half showing growth in both eyes. Patients exposed to sunlight and dust – particularly outdoor workers – were identified to be at higher risk.

PhilHealth Circular No. 2025-0021, effective 15 November, outlines comprehensive clinical guidelines for the treatment and surgical removal of pterygium. The new directive mandates strict quality control, including 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,” PhilHealth President and CEO Dr. Edwin Mercado said in Filipino. He added that the corporation continues to collaborate with specialists and strengthen monitoring mechanisms to deliver quality benefits.

The policy was developed in consultation with the Philippine Academy of Ophthalmology and the Philippine Cornea Society, integrating updated clinical standards specific to the Philippine setting. PhilHealth currently covers pterygium excision with graft under RVS 65426 and ocular surface reconstruction procedures for up to P59,085 (RVS 65780-65782).

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

The initiative is seen as part of the overarching health agenda of President Ferdinand Marcos Jr., aimed at lightening the burden of costly medical interventions while promoting preventive and quality-focused healthcare across the country.

PhilHealth urges its members and healthcare providers to familiarize themselves with the updated circular to ensure compliance and the proper use of benefits.