CurrentAetnaPolicy 0580

Low Vision Programs

Defines Aetna's coverage stance and clinical criteria for low vision programs, including evaluations, therapy, instruction, and orientation/mobility services for members with moderate to severe visual impairment; applies to Aetna members and participating providers.

Policy Summary

PayerAetna

PolicyLow Vision Programs

Policy CodePolicy 0580

Change TypeNo material change

Effective Date11/13/2001

Next Review DateJun 13, 2024

Key ActionDocument best corrected visual acuity, visual fields, functional impact, selected aids and instruction, and follow-up counseling when providing low vision program services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2severity categories

20/60BCVA moderate threshold

20/160BCVA severe threshold

V2600,V2610,V2615HCPCS not covered

07/28/2023Last review

Coverage Criteria

Medical necessity

Covered when ALL of the following are met

Eligibility: Member has moderate or severe visual impairment not correctable by conventional refractive meanssee definitions

Moderate and severe defined by BCVA and visual field criteria in policy

Definition of moderate visual impairment: Best corrected visual acuity (BCVA) is less than 20/60 in the better eye (including 20/70 to 20/160)BCVA <20/60 (better eye)

Per policy definitions

Definition of severe visual impairment: BCVA is less than 20/160 in the better eye (including 20/200 to 20/400) OR visual field diameter is 20° or less in the better eye (Goldman isopter III4e or equivalent)

Policy Summary

PayerAetna

PolicyLow Vision Programs

Policy CodePolicy 0580

Change TypeNo material change

Effective Date11/13/2001

Next Review DateJun 13, 2024

Key ActionDocument best corrected visual acuity, visual fields, functional impact, selected aids and instruction, and follow-up counseling when providing low vision program services.

SourceLink

On This Page

Most Aetna plans do not cover optical low vision devices (for example, magnified visual aids) or non‑optical low vision devices (for example, large‑print books, enlarged telephone dials, or talking machines) because vision aids are contractually excluded from coverage. Check the member's benefit plan description for specific coverage details. The HCPCS codes V2600, V2610, and V2615 are identified in this policy as codes for low vision aids that are not covered for the indications listed.

This policy addresses low vision programs limited to ophthalmologic low vision evaluations, testing, instruction in the use of visual aids, interviews, and counseling when medical necessity criteria are met for moderate or severe visual impairment. Coverage for program services is contingent on meeting the policy's medical necessity definitions for moderate and severe visual impairment rather than routine refractive correction.

Coding and Clinical Thresholds

HCPCS codes (not covered for indications listed)HCPCSNot Covered

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

ICD-10 codes (covered if selection criteria are met)ICD-10Covered

H53.461	Homonymous bilateral field defects
H43.469	Example code listed in ICD-10 group
H54.0X33	Blindness, both eyes
H54.10	Blindness, one eye, low vision other eye
H54.2X11	Low vision, both eyes
H54.40	Blindness, one eye
H54.50	Low vision, one eye

inv-05: Best corrected visual acuity (BCVA) thresholds for moderate and severe impairment

Moderate visual impairment (BCVA)Best corrected visual acuity (BCVA) is less than 20/60 in the better eye (includes 20/70 to 20/160)

Severe visual impairment (BCVA)Best corrected visual acuity (BCVA) is less than 20/160 in the better eye (includes 20/200 to 20/400)

Assessment eyeThresholds apply to the better eye

inv-06: Visual field diameter threshold for severe impairment

Severe visual field diameterVisual field diameter ≤ 20° in the better eye (largest field diameter for Goldman isopter III4e, 1/100 white test object or equivalent)

Measurement standardGoldman isopter III4e or equivalent

Applies toBetter eye

Provider Actions and Requirements

Prior Authorization

Prior authorization contingent on meeting medical necessity; excluded device PA typically not approved

Coverage for low vision program services is contingent on meeting the policy’s medical necessity criteria for moderate or severe visual impairment; prior authorization for devices that are contractually excluded (see HCPCS V2600, V2610, V2615) is typically not approved.

Coverage is limited to ophthalmologic low vision evaluations, testing, instruction, interviews and counseling when medical necessity criteria are met.
Prior authorization for optical or non‑optical low vision devices listed as not covered (V2600, V2610, V2615) is generally not granted.

Step Therapy

Deliver full low‑vision program components; no step therapy required

Provide comprehensive low vision care including assessment, objective testing, device selection/prescription, instruction in device use, and follow‑up counseling; no step therapy sequence is specified in the policy.

Assessment and testing: history of onset and effect on daily life; BCVA, visual fields, contrast sensitivity, color and glare testing as relevant.
Care components explicitly include selection/prescription of visual aids, instruction in correct use, and follow‑up interviews or counseling.

Documentation Required

Required clinical documentation for low‑vision services

Document the patient’s history of onset and the effect of visual impairment on daily activities, best corrected visual acuity, visual field testing, contrast sensitivity, color perception and glare sensitivity when relevant, near vision/reading evaluation, selected aids/instruction provided, and follow‑up counseling.

Record BCVA and visual field measurements to demonstrate moderate (<20/60) or severe (<20/160 or ≤20° field) impairment per policy definitions.
Include documentation of device selection, instruction given, and follow‑up interviews or counseling.

Denial Risk

Denied risk: low‑vision devices (V2600, V2610, V2615) typically not covered

Most Aetna plans do not cover optical or non‑optical low vision devices (HCPCS V2600, V2610, V2615); billing these HCPCS codes for excluded vision aids may result in denial.

HCPCS V2600 — Hand held low vision aids and other nonspectacle mounted aids
HCPCS V2610 — Single lens spectacle mounted low vision aids
HCPCS V2615 — Telescopic and other compound lens systems

Background

Low vision is a visual impairment that is not correctable by standard eyeglasses, contact lenses, medicine, or surgery and that interferes with activities of daily living. Causes include age‑related conditions (for example, macular degeneration), diabetes, glaucoma, cataract, injury, congenital conditions, and other disorders.

For this policy, moderate visual impairment is defined as best corrected visual acuity (BCVA) in the better eye of less than 20/60 (including BCVA in the 20/70 to 20/160 range). Severe visual impairment is defined as BCVA in the better eye of less than 20/160 (including 20/200 to 20/400) or a visual field diameter of ≤ 20° in the better eye (largest field diameter for Goldman isopter III4e or equivalent).

Definitions

inv-12: Moderate visual impairment definition (BCVA <20/60)

DefinitionModerate visual impairment: Best corrected visual acuity (BCVA) is less than 20/60 in the better eye (includes 20/70 to 20/160)

Threshold typeBCVA (better eye)

Clinical relevanceMember eligible for low vision program services when criteria met

inv-13: Severe visual impairment definition (BCVA <20/160 or visual field ≤ 20°)

Definition — BCVASevere visual impairment: Best corrected visual acuity (BCVA) is less than 20/160 in the better eye (includes 20/200 to 20/400)

Definition — Visual fieldOr visual field diameter is 20° or less in the better eye (Goldman isopter III4e or equivalent)

Thresholds apply toBetter eye

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