Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) Device
Customize your policy alerts
Sign up for all Alaska Medicaid policy alerts
Know when Alaska Medicaid releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Alaska Medicaid coverage, coding, prior authorization, billing, and reimbursement rules for Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) devices — both scleral cover shells and scleral contact lenses — and who may bill for them under Alaska Medicaid.
No material clinical or coverage changes in this revision.
Definitions
Coverage criteria for PROSE devices
Scleral cover shell coverage
Scleral cover shells (HCPCS V2627) are covered when used for the following indications:
Covered when any ONE of the following indications is met
- Treatment of an eye rendered sightless and shrunken by inflammatory disease.
- Treatment of 'dry eye' where the PROSE device serves as a substitute for the function of the diseased lacrimal gland.
Scleral contact lens coverage
Scleral contact lenses (HCPCS V2531) are covered only when resulting from or treating one of the listed medical conditions and are subject to contact lens limitations in 7 AAC 110.715(a)(2):
Covered when the device is the result of or treatment for ONE of the following conditions
- Cataract surgery.
- Aphakia.
- Keratoconus.
- Corneal degeneration.
- Rejection of an implant.
- Other medical reason requiring treatment with contact lens.
Bundling, repairs, modifications, and trial shells
Noncovered, bundled, and payment rules for PROSE devices, modifications, repairs, and trial shells:
Bundling and noncoverage rules
- Modifications for scleral contact lenses (HCPCS V2531) are not covered separately by Alaska Medicaid.
- Modifications to a scleral cover shell made at delivery or within 90 days thereafter, repairs due to normal wear within 90 days, and follow-up visits within 90 days are included in the V2627 reimbursement and not separately payable.
- Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery and are required due to a change in the beneficiary's condition.
- Repairs are covered for accidental damage or extensive wear; if repair expense exceeds estimated replacement cost, no payment for the excess amount.
- Replacement for loss or irreparable damage may be reimbursed without a treating practitioner's order when the original prosthesis still meets the beneficiary's medical needs.
- Follow-up visits more than 90 days after delivery that do not involve modification or repair are noncovered services.
Documentation requirements
Claim submission requirements for scleral contact lenses (HCPCS V2531):
Documentation required with claims for V2531
- Medical records justifying the medical need for the contact lenses must be submitted with the claim.
- An invoice for the lenses must be submitted with the claim.
- Claims received without medical records and an invoice will be denied.
Modifiers and bilateral billing
Billing modifiers and units guidance for HCPCS codes in this guidance:
Modifier and bilateral billing requirements
- The (RT) and/or (LT) modifiers must be used with all HCPCS codes pertaining to this guidance.
- For bilateral items billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service on each claim line.
Coding and code-level rules
| V2531 | Scleral Contact Lens, Gas Permeable, Per Lens |
| 92071 | Fitting of contact lens for treatment of eye surface disease |
| 92072 | Fitting of contact lens for management of corneal condition |
| 92310 | Contact lens services both eyes |
| 92311 | Contact lens services 1 eye where natural lens is absent |
| 92312 | Contact lens services both eyes where natural lens is absent |
| 92313 | Contact lens services for lenses covering entire cornea |
| 92314 | Contact lens services both eyes with fitting by independent technician |
Provider billing and authorization actions
Department prior authorization required for HCPCS V2627
Prior authorization from the department must be obtained to receive reimbursement for scleral cover shells (HCPCS V2627).
Submit medical records and invoice with V2531 claims
Claims for scleral contact lenses (HCPCS V2531) must include medical records justifying the medical need and an invoice for the lenses; claims submitted without these documents will be denied.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.