Notification

Refractive Lenses


Notification Issue Date: 04/05/2017

This version of the policy will become effective 05/05/2017.

  • The following criteria were removed:
  • Information on Scleral shell contact lenses
  • The following codes were removed from the policy:
V2627 Scleral cover shell
S0515 Scleral lens, liquid bandage device, per lens
  • The non-covered section of the policy, was revised in accordance with the Medicare.
  • The description section was revised.


  • Medicare Advantage Policy

    Title:Refractive Lenses
    Policy #:MA07.029b

    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.

    MEDICALLY NECESSARY

    INDIVIDUALS WITH APHAKIA
    For individuals with aphakia (i.e., with congenital absence of the lens or following the removal of a cataract without the insertion of an implanted interocular lens [IOL]), one of the following standard refractive lenses or combination of standard refractive lenses are considered medically necessary and, therefore, covered:
    • Bifocal lenses in frames; or
    • Trifocal lenses in frames; or
    • Lenses in frames for far vision and a separate pair of lenses in frames for near vision; or
    • Contact lenses for far vision, along with a pair of lenses in frames for near vision, and an additional pair of lenses in frames, when contact lenses are not being worn.

    Replacement lenses for individuals with aphakia (without an IOL) are considered medically necessary and, therefore, covered when the above criteria are met.

    INDIVIDUALS WITH PSEUDOPHAKIA
    For individuals with pseudophakia (i.e., natural lens removed and replaced with an intraocular lens [(IOL]), the initial pair of standard lenses in frames or contact lenses are considered medically necessary and, therefore, covered after each cataract surgery.

    If an individual has a cataract extraction with IOL insertion in one eye, and subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, coverage is limited to one pair of eyeglasses or contact lenses after the second surgery.

    If an individual has an existing pair of lenses in frames, has a cataract extraction with IOL insertion, and receives only new lenses, but not new frames after the surgery, new frames at a later date are not covered unless there is a subsequent cataract extraction with IOL insertion in the other eye.

    PRESCRIPTION REFRACTIVE LENSES FEATURES
    The following features are covered when the above coverage criteria for prescription refractive lenses are met and the medical necessity for the feature is supported in the documentation by the prescribing professional provider:
      • Anti-reflective coating (V2750), a clear lens treatment to decrease glare and internal/external reflections
      • Oversize lenses (V2780)
      • Polycarbonate lenses (V2784, S0580)
        • In addition, polycarbonate lenses or other impact-resistant materials are considered medically necessary and, therefore, covered for individuals with functional vision in only one eye. In this situation an impact-resistant material is covered for both lenses if the eyeglasses are covered.
      • Tinted lenses (V2745) and photochromatic lenses (V2744)
      • UV lenses (V2755) following cataract extraction

    NOT MEDICALLY NECESSARY
    • Tinted lenses (V2745) and photochromatic lenses (V2744) when used as sunglasses, and prescribed in addition to regular prosthetic lenses for an aphakic individual, are considered not medically necessary and, therefore, not covered.
    • The addition of UV protection (V2755) to polycarbonate lenses (S0580, V2784) are considered not medically necessary and, therefore, not covered.

    NONCOVERED ITEMS

    The following items or features are not covered by the Company because they are items or features not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.
      • Any lens customization such as, but not limited to:
        • Deluxe frames (V2025)
        • Deluxe lens feature (V2702) such as lens edge treatments and lens drilling
        • Frames or lenses add-ons without a covered lens(es)
        • Hydrophilic soft contact lenses (V2520–V2523) when used as a corneal dressing can be used as prescription lenses: incident to physician office)
        • Light-weight or thinness, high-index glass, or plastic (S0504, S0506, S0508, V2782, V2783)
        • Mirror coating (V2761) reflective lens treatments
        • Polarization (V2762)
        • Progressive lenses (V2781)
        • Scratch-resistant coating (V2760)
        • Specialty occupational multifocal lenses (V2786)
        • Low-vision aids (V2600-V2615), vision supplies, and accessories such as eyeglass cases (V2756), lens cleaning solution, and normal saline for contact lenses
        • The replacement of frames, eyeglass lenses, and contact lenses for individuals with pseudophakia.

    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, prescription refractive lenses are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this policy are met.

    However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

    Description

    Refractive lenses are used to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence. Refractive lenses can be used for individuals with pseudophakia ( i.e., a condition in which the natural lens has been replaced with an implanted intraocular lens [IOL]), aphakia (i.e., a condition in which the natural lens has been removed but there is no IOL), and congenital aphakia.

    Vision supplies and accessories are used for the care and maintenance of visual devices, including, but not limited to, prescription lenses.
    References


    Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD) Refractive Lenses (L33793). Effective 10/01/2015. Available at:
    https://med.noridianmedicare.com/documents/6547796/6558289/Refractive+Lenses.pdf/1d8d64e5-7147-434d-ad0e-b6828dffc482. Accessed January 20, 2017.

    Noridian Healthcare Solutions, LLC.Policy Article (A52499). Effective October 2015. Available at:https://med.noridianmedicare.com/documents/6547796/6558289/Refractive+Lenses.pdf/1d8d64e5-7147-434d-ad0e-b6828dffc482. Accessed January 20, 2017.



    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)

    H26.40 Unspecified secondary cataract

    H27.00 Aphakia, unspecified eye

    H27.01 Aphakia, right eye

    H27.02 Aphakia, left eye

    H27.03 Aphakia, bilateral

    Q12.3 Congenital aphakia

    Z96.1 Presence of intraocular lens

    Z98.41 Cataract extraction status, right eye

    Z98.42 Cataract extraction status, left eye

    Z98.49 Cataract extraction status, unspecified eye



    HCPCS Level II Code Number(s)

    MEDICALLY NECESSARY


    FRAMES
    V2020 Frames, purchases

    EYEGLASS LENSES
    V2100 Sphere, single vision, plano to plus or minus 4.00, per lens

    V2101 Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens

    V2102 Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens

    V2103 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

    V2104 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

    V2105 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2106 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

    V2107 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens

    V2108 Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

    V2109 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2110 Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per lens

    V2111 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

    V2112 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder, per lens

    V2113 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2114 Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens

    V2115 Lenticular (myodisc), per lens, single vision

    V2118 Aniseikonic lens, single vision

    V2121 Lenticular lens, per lens, single

    V2199 Not otherwise classified, single vision lens

    V2200 Sphere, bifocal, plano to plus or minus 4.00d, per lens

    V2201 Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens

    V2202 Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens

    V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

    V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

    V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

    V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

    V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

    V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

    V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

    V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

    V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2214 Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens

    V2215 Lenticular (myodisc), per lens, bifocal

    V2218 Aniseikonic, per lens, bifocal

    V2219 Bifocal seg width over 28mm

    V2220 Bifocal add over 3.25d

    V2221 Lenticular lens, per lens, bifocal

    V2299 Specialty bifocal (by report)

    V2300 Sphere, trifocal, plano to plus or minus 4.00d, per lens

    V2301 Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens

    V2302 Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens

    V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

    V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens

    V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens

    V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

    V2307 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

    V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

    V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

    V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

    V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

    V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

    V2314 Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens

    V2315 Lenticular, (myodisc), per lens, trifocal

    V2318 Aniseikonic lens, trifocal

    V2319 Trifocal seg width over 28 mm

    V2320 Trifocal add over 3.25d

    V2321 Lenticular lens, per lens, trifocal

    V2399 Specialty trifocal (by report)

    V2410 Variable asphericity lens, single vision, full field, glass or plastic, per lens

    V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens

    V2499 Variable sphericity lens, other type

    CONTACT LENSES

    V2500 Contact lens, PMMA, spherical, per lens

    V2501 Contact lens, PMMA, toric or prism ballast, per lens

    V2502 Contact lens PMMA, bifocal, per lens

    V2503 Contact lens, PMMA, color vision deficiency, per lens

    V2510 Contact lens, gas permeable, spherical, per lens

    V2511 Contact lens, gas permeable, toric, prism ballast, per lens

    V2512 Contact lens, gas permeable, bifocal, per lens

    V2513 Contact lens, gas permeable, extended wear, per lens

    V2520 Contact lens, hydrophilic, spherical, per lens

    V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens

    V2522 Contact lens, hydrophilic, bifocal, per lens

    V2523 Contact lens, hydrophilic, extended wear, per lens

    V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens modification, see 92325)

    V2531 Contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325)

    V2599 Contact lens, other type


    OTHER LENSES/MISCELLANEOUS

    S0500 Disposable contact lens, per lens

    S0512 Daily wear specialty contact lens, per lens

    S0580 Polycarbonate lens (list this code in addition to the basic code for the lens)

    V2700 Balance lens, per lens

    V2710 Slab off prism, glass or plastic, per lens

    V2715 Prism, per lens

    V2718 Press-on lens, Fresnel prism, per lens

    V2730 Special base curve, glass or plastic, per lens

    V2744 Tint, photochromatic, per lens

    V2745 Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens

    V2750 Anti-reflective coating, per lens

    V2755 U-V lens, per lens

    V2770 Occluder lens, per lens

    V2780 Oversize lens, per lens

    V2784 Lens, polycarbonate or equal, any index, per lens

    NOT COVERED

    THE FOLLOWING CODES ARE USED TO REPRESENT LENS, FRAMES, AIDS AND MISCELLANEOUS CODES:

    S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens

    S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per lens

    S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per lens

    S0510 Nonprescription lens (safety, athletic, or sunglass), per lens

    S0581 Nonstandard lens (list this code in addition to the basic code for the lens)

    S0590 Integral lens service, miscellaneous services reported separately

    S0595 Dispensing new spectacle lenses for patient supplied frame

    V2025 Deluxe frame

    V2600 Hand held low vision aids and other nonspectacle mounted aids

    V2610 Single lens spectacle mounted low vision aids

    V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system

    V2702 Deluxe lens feature

    V2756 Eye glass case

    V2760 Scratch resistant coating, per lens

    V2761 Mirror coating, any type, solid, gradient or equal, any lens material, per lens

    V2762 Polarization, any lens material, per lens

    V2781 Progressive lens, per lens

    V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens

    V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens

    V2786 Specialty occupational multifocal lens, per lens

    V2797 Vision supply, accessory and/or service component of another HCPCS vision code

    V2799 Vision item or service, miscellaneous



    Revenue Code Number(s)

    N/A


    Misc Code

    MODIFIERS:


    LT left side

    RT right side




    Coding and Billing Requirements






    Policy History

    MA07.029b
    05/05/2017
    • The following criteria were removed:
      • Information on Scleral shell contact lenses
    • The following codes were removed:
      V2627 Scleral cover shell
      S0515 Scleral lens, liquid bandage device, per lens
    • The non-covered section of the policy was revised in accordance with the Medicare.
    • The description section was revised.

    MA07.029a
    07/20/2016This version of the policy will become effective 07/20/2016.

    This policy has been revised to convey the company's coverage position on scleral shell contact lenses.

    MA07.029
    01/01/2015This is a new policy.

    Note: On 12/23/2014, this policy was identified for CPT code update, effective 01/01/2015.

    The following CPT narrative has been revised in this policy:
    • V2799 narrative revised
    01/01/2015This is a new policy.




    Version Effective Date: 05/05/2017
    Version Issued Date: 05/05/2017
    Version Reissued Date: N/A