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Defines medical necessity and coverage limits for eyeglasses, contact lenses, lens materials and lens features for members with aphakia, pseudoaphakia, congenital aphakia, and use of contact/scleral lenses as bandages; excludes routine vision benefit items unless member has a stand-alone vision plan or rider. Applies to Blue Cross Blue Shield Rhode Island products including BlueCHiP for Medicare and Commercial products.
Contact lenses and scleral bandages used as a bandage for promotion of healing are covered for BlueCHiP for Medicare and Commercial products.
Prior authorization review is not required.
This policy defines medical necessity and coverage limits for eyeglasses, contact lenses, lens materials and lens features for members with aphakia (absence of the lens), pseudoaphakia (intraocular lens implanted), congenital aphakia, and for contact/scleral lenses used as therapeutic bandages. It applies to Blue Cross & Blue Shield of Rhode Island products including BlueCHiP for Medicare and Commercial products. Effective date: 02/04/2007; policy last updated: 01/15/2019. Prior authorization review is not required.
| 92311 | Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, one eye: fitting |
| 92312 | Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, both eyes: fitting |
| 92313 | Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens |
| 92315 | Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, one eye |
| 92316 | Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes |
| 92317 | Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens fitting |
| 92352 | Fitting of spectacle prosthesis for aphakia; monofocal |
| 92071 | Fitting of contact lens to treat ocular surface disease |
| V2020 | Frames purchases |
| V2025 | Deluxe frame |
| 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 7.00, per lens |
| V2102 | Sphere, single vision, plus or minus 7.12 to plus or minus 20.00, per lens |
| V2104 | Spherocylinder, single vision, plano to plus or minus 4.00 sphere, 2.12 to 4.00 cylinder, per lens |
| V2105 | Spherocylinder, single vision, plano to plus or minus 4.00 sphere, 4.25 to 6.00 cylinder, per lens |
| V2106 | Spherocylinder, single vision, plano to plus or minus 4.00 sphere, over 6.00 cylinder, per lens |
| V2110 | Spherocylinder; single vision, plus or minus 4.25 to plus or minus 7.00 sphere, over 6.00 cylinder per lens |
| V2112 | Spherocylinder; single vision, plus or minus 7.25 to plus or minus 12.00 sphere, 2.25 to 4.00 cylinder, per lens |
Prior authorization not required
Prior authorization review is not required for these services.
Medical necessity documentation for bandage/contact lens use
When contact lenses or scleral bandages are billed as therapeutic bandages, documentation must support use as a bandage to promote healing for BlueCHiP for Medicare and Commercial products.
HCPCS accessory not separately reimbursed
V2797 is covered but not separately reimbursed when billed as an accessory/service component to another HCPCS vision code.
Coverage contingent on vision rider/stand-alone plan
Eyeglasses or contact lenses following cataract surgery, congenital aphakia, or for indications such as keratoconus are not covered under commercial products unless the member has a stand-alone vision plan or vision rider; absent a rider the member is responsible for payment.
Aphakia is the absence of the eye's crystalline lens due to surgical removal (e.g., cataract surgery), trauma, ulcer, or congenital anomaly; pseudophakia is the condition after implantation of an intraocular lens (IOL). When an IOL cannot safely be placed, patients may require eyeglasses or contact lenses to restore vision.
Intraocular lens types described include monofocal lenses (provide sharp focus at one distance and often require reading glasses), toric lenses (correct astigmatism by having greater power in one region of the lens), and presbyopia-correcting lenses such as progressive or multifocal IOLs intended to address near and distance vision.
Hydrophilic contact lenses can be used therapeutically as moist corneal bandages for acute or chronic corneal pathology and ocular surface disease (including corneal ulcers, erosions, keratitis, corneal edema, descemetocele, corneal ectasia, and anterior corneal dystrophy). Scleral lenses (scleral shells) fit over the entire exposed surface of the eye and may be used to improve vision, reduce pain and light sensitivity, and treat a range of disorders or injuries (for example: microphthalmia, corneal ectasia, Stevens-Johnson syndrome, Sjogren's, aniridia, neurotrophic keratitis, post-LASIK or post-transplant complications, chemical/burn injuries).
When used to promote healing as a bandage, contact lenses and scleral bandages are covered for BlueCHiP for Medicare and Commercial products; hydrophilic contact lens HCPCS codes listed in the policy are covered when used as corneal bandages. The policy also lists covered fitting CPT codes and specific V-codes for frames and lenses when criteria are met.
| Term | Definition |
|---|---|
| Aphakia | |
| Absence of the lens of the eye due to surgical removal, perforating wound or ulcer, or congenital anomaly. | |
| Pseudophakia | |
| Condition in which an intraocular lens is implanted to replace the natural lens. |
| Name | Number | Type | Effective Date |
|---|---|---|---|
| Scleral Shell | |||
| 80.5 | |||
| NCD | |||
Prior authorization review is not required.
Contact lenses and scleral bandages used as a bandage for promotion of healing are covered for BlueCHiP for Medicare and Commercial products.