| THE FOLLOWING CODES ARE CONSIDERED COVERED WHEN MEDICAL NECESSITY CRITERIA ARE MET, AND WHEN IN ACCORDANCE WITH THE INDIVIDUAL MEMBER BENEFIT CONTRACT: |
FRAMES
|
V2020
| Frames, purchases
|
| SINGLE VISION LENS |
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 |
BIFOCAL 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) |
TRIFOCAL LENS
|
| 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) |
VARIABLE ASPHERICITY LENS
|
| 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 LENS
|
| 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 |
V2524
| Contact lens, hydrophilic, spherical, photochromic additive, per lens
|
V2525
| Contact lens, hydrophilic, dual focus, per lens
|
V2526
| Contact lens, hydrophilic, with blue-violet filter, 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
|
| S0500 | Disposable contact lens, per lens |
| S0512 | Daily wear specialty contact lens, per lens |
| S0515 | Scleral lens, liquid bandage device, per lens |
| V2700 | Balance lens, per lens |
| V2770 | Occluder lens, per lens
|
SCLERAL COVER
|
| V2627 | Scleral shell cover |
|
| THE FOLLOWING CODES ARE CONSIDERED NON-COVERED ACCORDING TO THE INDIVIDUAL MEMBER BENEFIT CONTRACT: |
| VISION AIDS |
| 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 |
| DELUXE FRAME AND LENS |
| V2025 | Deluxe frame |
| V2702 | Deluxe lens feature |
MISCELLANEOUS
|
| 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 lenses |
S0516
| Safety eyeglass frames
|
S0518
| Sunglasses frames
|
| S0580 | Polycarbonate lens (list this code in addition to the basic code for the 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 |
| V2744 | Tint, photochromatic, per lens |
| V2745 | Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens |
| V2750 | Antireflective coating, per lens |
| V2755 | U-V lens, per lens |
| 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 |
| V2780 | Oversize lens, 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 |
| V2784 | Lens, polycarbonate or equal, any index, per lens
|
| V2786 | Specialty occupational multifocal lens, per lens
|
