PhilHealth Strengthens Member Protection, Guarantees Quality Care with Eye Surgery New Guidelines

The Philippine Health Insurance Corporation (PhilHealth) has issued guidelines on Pterygium Excision with Graft and Ocular Surface Reconstructive Surgeries (OSR). Pterygium, most commonly known as “pugita sa mata” is a triangular, fleshy, fibrovascular sheet originating from the conjunctiva and extending to the corneal limbus and beyond. 

A study at the Philippine General Hospital (PGH) found that about 2% of new eye patients were diagnosed with pterygium, mostly aged around 47 years, with slightly more women (53%) affected. Nearly half had growth in both eyes, and 42% worked outdoors, exposing them to sunlight and dust, which are key risk factors. Most patients sought consultation due to visible eye growth, and doctors recommended surgical removal with conjunctival grafting to prevent recurrence and protect vision. 

Surgery is necessary when it causes vision problems, irritation, and among others. To ensure patient safety and effective treatment, quality measures such as accredited facilities, qualified surgeons, proper surgical techniques, and post-operative care must be observed. This policy aims to standardize care, prevent complications, and promote consistent, high-quality eye health services for all PhilHealth members.

PhilHealth Circular No. 2025-0021, effective November 15, 2025, is a new policy that sets clear quality standards and clinical guidelines for the treatment of pterygium. This initiative aims to ease the burden of Filipinos with this condition, reflecting the health agenda of President Ferdinand R. Marcos Jr. 

“Ito ang aming hakbang upang tiyakin na ang bawat miyembro ng PhilHealth ay makatatanggap ng pinakamataas na posibleng pamantayan ng pangangalaga sa mata,” ayon kay Dr. Edwin M. Mercado, Pangulo at Punong Tagapagpatupad ng PhilHealth.

“Kami ay nakikipagtulungan sa mga ekspertong doktor at pinapalakas pa namin ang aming mga sistema ng pagsubaybay upang matagumpay na matupad ang mandato ng PhilHealth na makapaghatid ng benepisyong may kalidad.“, dagdag pa ni Mercardo.

Developed in consultation with experts from the Philippine Academy of Ophthalmology (PAO) and the Philippine Cornea Society, Inc. (PCSI), the policy focuses on quality of care and patient safety and ensures that surgical procedures received by members meet the latest, high standards of care applicable in the local settings.

PhilHealth currently covers pterygium excision with graft for (RVS 65426) and P59,085 for ocular surface reconstruction (RVS 65780, 65781, 65782).

Under the new policy, PhilHealth will implement a maximum claim limit for eye surgeons to help ensure patient safety and proper utilization of benefits. This limit does not apply to procedures performed by residents-in-training in accredited government and private health facilities with a Philippine Board of Ophthalmology (PBO)-accredited residency training program, thereby promoting continuous quality training standards.

PhilHealth encourages members and healthcare providers to familiarize themselves with PhilHealth Circular No. 2025-0021 to ensure full compliance and proper utilization of benefits.  The new policy is downloadable in www.philhealth.gov.ph.