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Refractive Lenses
MA07.029e

Policy

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.​

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 intraocular 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 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.
NON COVERED 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.

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 Misspelled WordMedi​care 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 10/01/2020. Available at: LCD - Refractive Lenses (L33793) (cms.gov). Accessed November 19, 2025.

Noridian Healthcare Solutions, LLC.Policy Article (A52499). Effective October 2020. Available at: Article - Refractive Lenses - Policy Article (A52499) (cms.gov)​. Accessed November 19, 2025.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
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, Misspelled Wordplano 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 Misspelled WordSpherocylinder, single vision, Misspelled Wordplano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2104 Misspelled WordSpherocylinder, single vision, Misspelled Wordplano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2105 Misspelled WordSpherocylinder, single vision, Misspelled Wordplano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2106 Misspelled WordSpherocylinder, single vision, Misspelled Wordplano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

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

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

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

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

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

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

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

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

V2115 Lenticular (Misspelled Wordmyodisc), per lens, single vision

V2118 Misspelled WordAniseikonic lens, single vision

V2121 Lenticular lens, per lens, single

V2199 Not otherwise classified, single vision lens

V2200 Sphere, bifocal, Misspelled Wordplano 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 Misspelled WordSpherocylinder, bifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2204 Misspelled WordSpherocylinder, bifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2205 Misspelled WordSpherocylinder, bifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2206 Misspelled WordSpherocylinder, bifocal, Misspelled Wordplano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

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

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

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

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

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

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

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

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

V2215 Lenticular (Misspelled Wordmyodisc), per lens, bifocal

V2218 Misspelled WordAniseikonic, per lens, bifocal

V2219 Bifocal Misspelled Wordseg width over 28mm

V2220 Bifocal add over 3.25d

V2221 Lenticular lens, per lens, bifocal

V2299 Specialty bifocal (by report)

V2300 Sphere, trifocal, Misspelled Wordplano 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 Misspelled WordSpherocylinder, trifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2304 Misspelled WordSpherocylinder, trifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens

V2305 Misspelled WordSpherocylinder, trifocal, Misspelled Wordplano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens

V2306 Misspelled WordSpherocylinder, trifocal, Misspelled Wordplano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

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

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

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

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

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

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

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

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

V2315 Lenticular, (Misspelled Wordmyodisc), per lens, trifocal

V2318 Misspelled WordAniseikonic lens, trifocal

V2319 Trifocal Misspelled Wordseg width over 28 mm

V2320 Trifocal add over 3.25d

V2321 Lenticular lens, per lens, trifocal

V2399 Specialty trifocal (by report)

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

V2430 Variable Misspelled Wordasphericity lens, bifocal, full field, glass or plastic, per lens

V2499 Variable Misspelled Wordsphericity 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

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/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 Misspelled Wordnonspe​ctacle 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

Modifiers

LT left side

RT right side

Coding and Billing Requirements

Policy History

Revisions From MA07.029e:​
​12/19/2025
​This policy has be​en reissued in accordance with the Company's annual review process.
​01/08/2025

​​This policy has been reissued in accordance with the Company's annual review process.​
​01/01/2024
​​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
10/01/2023

​This policy has been identified for the​ HCPCS code update, effective 10/01/2023.

The following HCPCS code has been added to this policy:

V2526 Contact lens, hydrophilic, with blue-violet filter, per lens​

Revisions From MA07.029d:​
04/01/2022

​This policy has been identified for the​ HCPCS code update, effective 04/01/2022.

The following HCPCS code has been added to this policy:

V2525 Contact lens, hydrophilic, dual focus, per lens

Revisions From MA07.029c:
11/17/2021​

​This policy has been reissued in accordance with the Company's annual review process.
​10/01/2020This policy has been updated for the ICD-10 CM code update, effective 10/01/2020.

The following HCPCS code has been added to the policy:

V2524 Contact lens, hydrophilic, spherical, photochromic additive, per lens

Revisions From 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.

Revisions From 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.

Revisions From 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.

1/1/2024
1/1/2024
12/19/2025
MA07.029
Claim Payment Policy Bulletin
Medicare Advantage
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.