Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Eye Prostheses and Scleral Cover Shell
Policy #:MA05.050a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

EYE PROSTHESIS

An eye prosthesis is considered medically necessary and, therefore, covered for an individual with an absence or shrinkage of an eye due to a birth defect, trauma, or surgical removal.

Polishing and resurfacing (V2624) is considered medically necessary and, therefore, covered twice per year.

One enlargement (V2625) or reduction (V2626) of the prosthesis is covered. Additional enlargements or reductions may be considered medically necessary and are, therefore, covered, when there is adequate documentation that supports medical necessity.

SCLERAL COVER SHELL

A scleral cover shell is considered medically necessary and, therefore covered for an individual with either of the following indications:
  • For treatment of an eye rendered sightless and shrunken by inflammatory disease
  • For treatment of “dry eye” where a scleral cover shell serves as a substitute for the function of the diseased lacrimal gland

Trial scleral cover shells are not eligible for separate reimbursement. They are included in the reimbursement for the scleral cover shells (V2627).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, an eye prosthesis or scleral shell is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

EYE PROSTHESIS

An eye prosthesis, or artificial eye, is a prosthetic device used to simulate a natural eye. An ocular prosthesis does not restore lost vision. The primary purpose of an ocular prosthesis is to maintain the volume of the eye socket and to restore appearance to that of a natural eye. Ocular prostheses can be made to fit many different types of eye sockets and their associated conditions.

SCLERAL SHELL

A scleral shell cover is a prosthetic device that fits over the entire exposed surface of the eye, as opposed to a corneal contact lens, which covers only the central non-white area encompassing the pupil and iris.

Scleral shell covers in conjunction with other treatment may eliminate the need for surgical enucleation and prosthetic implant and aide in supporting the surrounding orbital tissue. Scleral shell covers are occasionally used in combination with artificial tears in the treatment of "dry eye," caused by a variety of etiology. In addition, scleral shell covers are often used for an eye that has been rendered sightless and shrunken by inflammatory disease.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Scleral Shell (80.5). Longstanding national coverage determination. [CMS website]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?MCDId=15&ExpandComments=n&McdName=Thomson+Micromedex+DrugPoints+Compendium+Revision+Request+-+CAG-00390&mcdtypename=Compendia&MCDIndexType=6&NCDId=235&ncdver=1&bc=AgAEAAAAAAAA&. Accessed January 4, 2019.

Noridian Healthcare Solutions. Local Coverage Determination(L33737). Eye Prostheses. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2017). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed January 4, 2019.

Noridian Healthcare Solutions. Local Coverage Article(A52462). Eye Prostheses.[Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2017). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed January 4, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



V2623 Prosthetic eye, plastic, custom

V2624 Polishing/resurfacing of ocular prosthesis

V2625 Enlargement of ocular prosthesis

V2626 Reduction of ocular prosthesis

V2627 Scleral cover shell

V2628 Fabrication and fitting of ocular conformer

V2629 Prosthetic eye, other type


THE FOLLOWING CODE IS USED TO REPRESENT TRIAL SCLERAL COVER SHELLS:

L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code


Revenue Code Number(s)

N/A


Misc Code

MODIFIERS:


RT Right side (used to identify procedures performed on the right side of the body)

LT Left side (used to identify procedures performed on the left side of the body)


Coding and Billing Requirements

CODING GUIDELINES

A trial scleral shell should be billed with code L9900.

The right (RT) and/or left (LT) modifiers should be used with all HCPCS codes in this policy.





Policy History

MA05.050a
02/12/2020This policy has been reissued in accordance with the Company's annual review process.
02/13/2019This policy has been reviewed and reissued to communicate the Company's continuing position for Eye Prostheses and Scleral Cover Shell.
04/25/2018 This policy has been reviewed and reissued to communicate the Company's continuing position for Eye Prostheses and Scleral Shell Cover.
04/07/2017 This version of the policy will become effective 04/07/2017.
  • The following criteria have been added to this policy:

SCLERAL COVER SHELL

A scleral cover shell cover is considered medically necessary and, therefore covered for an individual with either of the following indications:
  • For treatment of an eye rendered sightless and shrunken by inflammatory disease.
  • For treatment of “dry eye” where a scleral cover shell serves as a substitute for the function of the diseased lacrimal gland.


MA05.050
10/26/2016This policy has been reviewed and reissued to communicate the Company's continuing position for eye prostheses.
08/19/2015This policy has been reviewed and reissued to communicate the Company's continuing position for eye prostheses.
01/01/2015This is a new policy.






Version Effective Date: 04/07/2017
Version Issued Date: 04/07/2017
Version Reissued Date: 02/14/2020