Notification



Notification Issue Date:



Claim Payment Policy


Title:Prescription Lenses and Visual Devices

Policy #:07.13.13c

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

COVERED

Based on a member's benefit, prescription lenses are covered for the following:
  • Initial contact lenses prescribed for the treatment of infantile glaucoma
  • Initial corneal or scleral lenses prescribed in connection with the treatment of keratoconus or to reduce a corneal irregularity other than astigmatism
  • Initial scleral lenses prescribed to retain moisture in cases where normal tearing is not present or adequate
  • Initial pair of basic eyeglasses when prescribed to perform the function of a human lens in individuals with aphakia as a result of accidental injury, trauma, or ocular surgery
  • Initial pinhole glasses prescribed for use after surgery for a detached retin

Scleral shells are covered when prescribed to support orbital tissue in an individual with an existing blind or shrunken eye.

NOT COVERED

The following items or services are considered a benefit contract exclusion and, therefore, not eligible for reimbursement consideration.
  • Deluxe frames (V2025)
  • Lenses that do not require a prescription (S0510)
  • Any lens customization such as, but not limited to:
    • Tinting (V2744, V2745).
    • Deluxe lens feature (V2702) such as lens edge treatments, and lens drilling, light-weight or thinness, high-index glass or plastic (S0504, S0506, S0508, V2782, V2783), polycarbonate or similar material (V2784, S0580), specialty occupational multifocal lenses (V2786)
    • Anti-reflective coatings (V2750)
    • UV lenses or coatings (V2755)
    • Scratch-resistant coatings (V2760)
    • Mirror coating (V2761) reflective lens treatments
    • Polarization (V2762)
    • Oversize lenses (V2780)
    • Progressive lenses (V2781)
    • Nonstandard lens (S0581)
  • Low-vision aids (V2600-V2615), vision supplies, and accessories such as eyeglass cases (V2756), lens cleaning solution, and normal saline for contact lenses.
  • Integral lens service (S0590)
  • Dispensing new spectacle lens for patient supplied frame (S0595)

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must reflect the medical necessity of the care and services 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.

An order for each item billed must be signed and dated by the professional provider who is treating the member and kept on file by the supplier. Medical record documentation must include a shipment confirmation or member's receipt of supplies and equipment. 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, prescription refractive lenses are covered as durable medical equipment under the medical benefits of most of the Company’s products when the medical necessity criteria listed in this policy are met.

Coverage and reimbursement for the repair and/or replacement of prescription refractive lenses vary by product and/or group contract. Therefore, individual member benefits must be verified.

Contact lenses, glasses with prescription lenses, and vision devices are covered for a narrow set of indications as indicated in this policy. Additional coverage may be available through an individual member's vision plan. For information relating to the supply of routine contact lenses, prescription glasses, and vision devices, contact the appropriate vision benefit administrator.

Description

In normal human vision, light rays passing through the cornea and natural crystalline lens of the eye are focussed on the retina from where they are transmitted as electrical impulses via the optic nerve to the brain for interpretation. In some individuals, however, refractive defects may cause light rays to focus either behind or in front of the retina: far-sightedness and near-sightedness, respectively.

In instances, where defects of the natural crystalline lens, or the absence of the lens, compromise vision, the defects are usually corrected with refractive lenses (either eyeglasses or conventional contact lenses). These lenses are prescribed by a healthcare professional to meet the visual needs of an individual, according to the individual's unique ophthalmologic condition and may be made of various materials, tints, and sizes.

Refractive lenses prescribed in children may require frequent adjustments. Children who are aphakic (an ophthalmological condition characterized by the loss of the natural crystalline lens) or pseudophakic (a condition in which the lens is replaced with an intraocular lens), for example, present special age-related challenges: as the child's eye continues to grow, frequent visual examinations and changes of prescription lenses are necessary to accommodate growth. Prescription lenses, whether in eyeglasses or contacts, must be changed to address individual pediatric needs to ensure optimal visual development.

Low-vision aids such as hand-held magnifying glasses, are devices designed to assist impaired vision. Vision aid devices such as pinhole glasses may be used after surgery for a detached retina. Pinhole glasses contain a series of small perforations filling an opaque sheet of plastic in place of each lens. The perforations reduce the width of the diverging light rays, allowing a narrow beam of light to enter through the center of the pupil of the eye. The reduced amount of light on the retina may enable an individual with retinal damage to see clearer images.

Scleral shells (or shields) are hard contact lenses that fit over the entire exposed surface of the eye as opposed to corneal contact lenses which cover only the central nonwhite portion of the eye (the pupil and iris). Scleral shells are typically prescribed in individuals with pthisis bulbi, a condition characterized by a shrunken non-functional eye caused by inflammation, injury, or other eye diseases. In these individuals, scleral shells obviate the need for enucleation of the eye. Scleral shells are also occasionally utilized in individuals with chronic dry eye caused by under-active lacrimal glands. In these individuals, scleral shells prevent drying out and eliminate the need for constant application of artificial tears.

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


Benefits Contracts

American Academy of Ophthalmology (AAO). Preferred Practice Pattern: Cataract in the Adult Eye. 2011. Second printing 2008. [AAO Web site]. Available at: http://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp--october-2011 Accessed December 08, 2017.

American Academy of Ophthalmology (AAO). Clinical statements; Cataract/Anterior Segment. 2006. [AAO Web site] available at: http://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp--october-2011 Accessed December 08, 2017.

American Academy of Ophthalmology (AAO). Refractive Errors & Refractive Surgery PPP-2013. [AAO Web site] available at: http://www.aao.org/preferred-practice-pattern/refractive-errors--surgery-ppp-2013 Accessed December 08, 2017.

American Academy of Ophthalmology, Physician Consortium for Performance Improvement®, National Committee for Quality Assurance. Eye care physician performance measurement set. Chicago (IL): American Medical Association, National Committee for Quality Assurance; 2007 Oct.

American Academy of Pediatrics. Eye Examination and Vision Screening in Infants, Children, and Young Adults. Policy Statement, Revised April 1, 2003. Pediatrics. Vol. 111 No. 4 April 2003, pp. 902-907. Available at:http://www.aao.org/clinical-statement/vision-screening-infants-children--2013 Accessed December 08, 2017.

American Optometric Association. (AOA) Eye Glasses [AOA Web site]. Available at: http://www.aao.org/clinical-statement/glasses-as-medical-necessity--2013. Accessed December 08, 2017.

Cataract National Dataset electronic multicentre audit of 55,567 operations: updating benchmark standards of care in the United Kingdom and internationally. 2009. Macmillan Publishers Limited All rights reserved 0950-222X/09. Eye. (2009) 23, 38–49. Available at:http://www.nature.com/eye/journal/v23/n1/pdf/6703015a.pdf. Accessed December 08, 2017.

Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Scleral Shell (NCD 80.5) Available at:https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=235&ncdver=1&bc=AgAAQAAAAAAAAA%253D%253D&. Accessed December 08, 2017.

Erickson Labs Northwest - A personalized approach to prosthetic eyes. Scleral Cover Shells; Ocular Prosthesis: Erickson Labs.2011. Available at: http://www.ericksonlabs.com/v/Artificial_Eyes/scleral_shells.asp. Accessed December 08, 2017.
Infant Aphakia Treatment Study Group, Lambert SR, Lynn MJ, et al. Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years. JAMA Ophthalmology. 2014; 132(6): 676–682.

Moseley M, Hill A. Contrast sensitivity testing in clinical practice. Br J Ophthalmol. 1994;78:795-797. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC504940/pdf/brjopthal00034-0063.pdf. Accessed December 08, 2017.

Novitas Solutions Inc.LCD, L35091 - Cataract Surgery, Revised October 1, 2015. [HMS Web site].https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35091&ContrId=318&ver=6&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Final&s=45&KeyWord=cataract+surgery&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d& Accessed December 08, 2017.

National Eye Institute, National Institutes of Health, Department of Health and Human Services, U.S.A. . http://www.nei.nih.gov/health/cataract/Accessed December 08, 2017.

National Heritage Insurance Company (NHIC). Refractive Lenses, L33793 . Revised 10/01/2015. [NHIC Web site.] Available at: http://www.medicarenhic.com/viewdoc.aspx?id=3181. Accessed December 08, 2017.

National Institute for Health and Clinical Excellence (NICE), Interventional Procedures Programme. Interventional procedure overview of the implantation of accommodating intraocular lenses during cataract surgery. August 2006. [NICE Web site.] Available at: http://www.nice.org.uk/nicemedia/pdf/ip/363overview.pdf. December 08, 2017.

Roger Chou, Tracy Dana, Bougatsos C. Clinical Guidelines. Screening Older Adults for Impaired Visual Acuity: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. Available at: http://www.ahrq.gov/clinic/uspstf09/visualscr/viseldart.pdf.Accessed December 08, 2017.

Royal College of Ophthalmologists (RCO). Cataract surgery guidelines. London, United Kingdom. 2004. [RCO Web site]. Available at: http://www.rcophth.ac.uk/docs/publications/CataractSurgeryGuidelinesMarch2005Updated.pdf. Accessed December 08, 2017.

Royal College of Ophthalmologists (RCO). The Surgical Management of Infantile Cataract. Focus Spring 2011. [RCO Web site]. Available at: http://www.rcophth.ac.uk/page.asp?section=355&sectionTitle=Focus+Articles. Accessed December 08, 2017.

US Department of Health. Technology Assessment. Vision Rehabilitation for Elderly Individuals with low vision or blindness. October 6, 2004. [AHRQ Web site]. Available at:
http://www.cms.gov/InfoExchange/downloads/RTCvisionrehab.pdf. Accessed December 08, 2017.

US Preventive Services Task Force. Chapter 33: screening for visual impairment. In: Guide to Clinical Preventive Services. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; 1996. Available at: http://www.guideline.gov/content.aspx?id=14839 Accessed December 08, 2017.

Vance T. Intraocular Cataract Lenses (IOLs): Premium; Aspheric; Toric. September 2015. Available at: http://www.allaboutvision.com/conditions/iols.htm. Accessed December 08, 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)

See Attachment A.


HCPCS Level II Code Number(s)

See Attachment A.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Prescription Lenses and Visual Devices
Description: Contains the applicable codes for prescription lenses and visual devices for Commercial (non-Medicare Advantage) members



Policy History

Revisions from 07.13.13c
10/01/2018This policy has been updated for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to the policy:
H10.821: Rosacea conjunctivitis, right eye
H10.822: Rosacea conjunctivitis, left eye
H10.823: Rosacea conjunctivitis, bilateral
H10.829: Rosacea conjunctivitis, unspecified eye


Revisions from 07.13.13b
03/28/2017This version of the policy will become effective on 03/28/2018.

The policy has been reviewed to communicate the Company’s continuing position on Prescription Lenses and Visual Devices.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Effective 10/05/2017 this policy has been updated to the new policy template format.



Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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