With all of the focus in recent years on the younger cataract patient, it would be easy to lose sight of what’s going on with the more conventional, “standard-age” cataract patient of—pick a number—70 or more years of age. We decided to address that with a specific article this month (p. 38) on meeting the needs of these patients, and with our cover story (p. 20). The latter deals with the oculoplastic considerations and potential complications in the elderly cataract patient.

It’s no revelation that elderly patients tend to have more issues with their lids, their lashes, their tear ducts and other extraocular problems that may need to be addressed in conjunction with their cataracts. What might be a revelation to some, though, is the increasing degree of Medicare billing for lid surgery. A report in late May by the Center for Public Integrity, a nonprofit investigative news organization, finds that from 2001 to 2011, eyelid lifts charged to Medicare more than tripled to 136,000 annually, with billing in the period quadrupling to $80 million a year, and the number of physicians performing the surgeries doubling.

At issue is medical necessity. As Medicare does not cover purely cosmetic, elective procedures, the case must be made that the patient is suffering a functional visual deficit because of the condition.

The report takes pains to point out that factors such as rising patient awareness of plastic surgery options thanks to reality television, and changing demands of patients in this age group play a role in the surge. But it adds that “Surgeons who bill Medicare for large numbers of eyelid surgeries dot a map of the United States. Yet 11 of the 20 highest billers in 2008 were in Florida, which is both an elderly mecca and the country’s foremost magnet for questionable Medicare billing.”

One top biller in South Florida, according to the data, “billed Medicare more than $800,000 in 2008 for about 2,200 eyelid lifts,” for an average of six a day, including weekends. This same doctor was also a top biller in 2006 and 2007.

The other shoe fell this week and it’s something all surgeons who participate in Medicare need to know about. In order to obtain the data that served as the basis for the report, the Center’s reporters had to agree to maintain the anonymity of any individual surgeons about whose billing practices they would report. A federal judge this week struck down a decades-old injunction barring public access to a confidential database of Medicare insurance claims, essentially removing that cloak of anonymity. The AMA has suggested that it will appeal the decision, and it’s uncertain how far the ruling extends but the implications for surgeons’ privacy could be substantial.

Again, no one has suggested any widespread gaming of the system by plastic or ophthalmic surgeons. But those who might be just lost some cover.