Blue Cross Blue Shield RI Therapeutic Eyewear Coverage

Medical Necessity and Coverage Rules

Aphakia — medically necessary coverage

Covered when prescribed by the treating physician and medically necessary in aphakia:

Aphakia coverage: Member is aphakic (no implanted IOL after cataract removal or congenital absence of lens) and eyewear or contact lenses are prescribed to correct vision or manage condition.

Permitted corrective options: Bifocal lenses in frames OR lenses in frames for far vision and lenses in frames for near vision OR contact lens(es) for far vision with compensatory near lenses in frames; replacement lenses when medically necessary.

When contact lens(es) for far vision are prescribed, payment includes lenses in frames for near vision to be worn with contacts and lenses to be worn when contacts are removed.

Additional covered lens features: Anti-reflective coating OR tints OR oversize lenses OR UV protection when medically necessary and prescribed.

Material restriction: Lenses made of polycarbonate or other impact materials are covered only for members who have functional vision in only one eye.

Pseudoaphakia — limited coverage

For pseudophakia (IOL implanted) coverage is limited:

Pseudophakia coverage limits: Coverage limited to one pair of standard frames or contact lenses, and bifocal or trifocal lenses; replacement frames, eyeglass lenses and contact lenses are not covered.

If two sequential cataract surgeries occur and no eyewear was provided between them, coverage is for only one pair after the second surgery. If only lenses (not frames) are provided after surgery, future new frames are not covered unless following subsequent cataract extraction in the other eye.

Therapeutic contact/scleral lenses

Therapeutic contact lenses and scleral shells:

Therapeutic hydrophilic contact lenses: Hydrophilic contact lenses used as moist corneal bandages for treatment of acute or chronic corneal pathology, dry eye, corneal ulcers/erosion, keratitis, corneal edema, descemetocele, corneal ectasia, Mooren's ulcer, anterior corneal dystrophy, and other therapeutic reasons are covered; not covered when used to treat nondiseased refractive errors.

Scleral lenses (scleral shell or gas permeable scleral lenses) may be used and covered for severe ocular surface disorders, corneal disease, or injuries as described (e.g., Stevens–Johnson syndrome, neurotrophic keratitis, post‑LASIK complications) when prescribed for therapeutic indication.

Documentation should support the therapeutic indication and clinical need.

Fitting code: Fitting of therapeutic contact lenses to treat ocular surface disease (CPT 92071) is a covered component when applicable.

Use appropriate HCPCS/CPT codes for lens type and fitting.

Low-vision aids (conditional)

Low-vision aids coverage condition

Low-vision aid coverage when prior surgery exists: HCPCS V2600, V2610, V2615 are covered when one of the listed ophthalmic surgery codes (66920, 66930, 66940, 66982, 66983, 66984, 66988, 66989, 66991) was filed within the previous 9 months.9 months

Must have qualifying surgical code on file within 9 months.

Contact lenses as corneal bandage (covered)

Therapeutic contact lens/corneal bandage coverage

Corneal bandage/contact lens: Hydrophilic contact lens HCPCS codes V2520–V2523 and CPT 92071 (fitting of contact lens to treat ocular surface disease) are covered when used as a corneal bandage or to treat ocular surface disease.

Documentation should support therapeutic indication and fitting.

The policy specifies that UV coating on polycarbonate lenses is considered not medically necessary and therefore not covered when billed for aphakia/pseudophakia indications. It also states that tinted lenses, including photochromatic lenses used as sunglasses when prescribed in addition to regular prescription glasses are not medically necessary. These exclusions are drawn directly from the aphakia and hydrophilic contact lens sections and should be considered when documenting medical necessity and submitting claims.

For therapeutic contact lens indications, hydrophilic lenses are covered when used as a corneal bandage or for treatment of corneal pathology, but explicitly not covered when used solely for refractive/nondiseased ametropia or astigmatism. Ensure that documentation supports a therapeutic indication (e.g., corneal ulcer, keratitis, ocular surface disease) when billing hydrophilic contact lens codes.

Certain sections of the policy contain only HCPCS V-code and descriptor listings without additional narrative medical-necessity discussion. When a section lists codes and power/cylinder ranges (for example in the single-vision, bifocal, and related lens tables), treat those listings as the authoritative mapping between lens types/power ranges and the corresponding V-codes for billing and authorization purposes.

Because those code-only sections do not restate coverage logic, refer to the policy's coverage criteria and documentation requirements for clinical indications, medical necessity, and allowable features when deciding coverage and preparing claims.

HCPCS code V2797 (Vision supply, accessory and/or service component of another HCPCS vision code) is listed as covered but with the specific caveat that it is not separately reimbursed. Do not bill V2797 as an independent reimbursable item; include it only as an ancillary component per billing guidance.

The policy clarifies that eyewear and contact lenses provided for purely cosmetic or refractive purposes (for example, correcting nondiseased refractive errors or providing sunglasses in addition to prescription glasses) are not medically necessary and therefore not covered under this policy. Therapeutic coverage is limited to documented clinical indications such as aphakia, ocular surface disease, corneal pathology, or other specified conditions.

When prescribing or billing for contact lenses or spectacles, ensure clinical documentation demonstrates a therapeutic need rather than a cosmetic or routine refractive correction to avoid denials.

Several code-listing chunks present HCPCS descriptors and power/cylinder thresholds but do not include explicit standalone statements phrased as 'not medically necessary' within those specific chunks. Coverage determinations should therefore be based on the policy's coverage criteria and exclusion sections rather than the standalone code tables.

Always cross-reference code selections with the policy's coverage criteria and exclusion language to determine whether a given item is medically necessary for the member's clinical presentation.

If services or items are determined to be not medically necessary or otherwise non-covered under the member's plan, the provider may not bill the member unless the member has been informed in advance and agreed in writing to accept financial responsibility. Verify member-specific benefits and eligibility against the subscriber agreement or employer contract and contact the provider call center for member-specific questions.

This policy is informational and not a guarantee of payment; providers should follow participation agreements and applicable billing rules when submitting claims and discussing potential member liability.

Billing Codes and HCPCS/CPT Guidance

Medicare Advantage covered CPT Codes for aphakia/pseudophakia fittingsCPTCovered

92311	Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, one eye.
92312	Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, both eyes.
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, 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.
92352	Fitting of spectacle prosthesis for aphakia; monofocal

Frames (HCPCS V-codes)HCPCSCovered

V2020	Frames purchases
V2025	Deluxe frame

Lenses (HCPCS V-codes)HCPCSCovered

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	Sphero cylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens
V2104	Sphero cylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens
V2105	Sphero cylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens
V2106	Sphero cylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens
V2107	Sphero cylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to 2.00d cylinder, per lens
V2108	Sphero cylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, .12 to 2.00d cylinder, per lens
V2109	Sphero cylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

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Bifocal lensesHCPCS

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	Sphero cylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens
V2204	Sphero cylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens
V2205	Sphero cylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens
V2206	Sphero cylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens
V2207	Sphero cylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens
V2208	Sphero cylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens
V2209	Sphero cylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

1–10 of 21

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Trifocal lensesHCPCS

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 20.00d, per lens
V2303	Sphero cylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens
V2304	Sphero cylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder, per lens
V2305	Sphero cylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens
V2306	Sphero cylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens
V2307	Sphero cylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere
V2309	Sphero cylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens
V2310	Sphero cylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

1–10 of 20

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Variable asphericity lensesHCPCS

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 asphericity lens, other type

Contact lensesHCPCS

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

Contact lens and bifocal lens HCPCS codesHCPCSCovered

V2212	Sphero cylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens
V2213	Sphero cylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens
V2214	Sphero cylinder, 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
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

1–10 of 19

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Single-vision and bifocal lens HCPCS codesHCPCSCovered

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	Sphero cylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens
V2111	Sphero cylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, .25 to 2.25d cylinder, per lens
V2112	Sphero cylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder
V2113	Sphero cylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per 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

Low-vision aids and miscellaneous lens modificationsHCPCSCovered

V2600	Handheld 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
V2700	Balance lens, per lens
V2710	Slab off prism, glass or plastic, per lens
V2715	Prism, per lens
V2718	Press-on lens, fresnell prism, per lens
V2730	Special base curve, glass or plastic, per lens
V2750	Anti-reflective coating, per lens
V2760	Scratch resistant coating, per lens

1–10 of 11

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Fitting code relevant to therapeutic contact lens useCPTCovered

92071

Fitting of contact lens to treat ocular surface disease

Surgical codes triggering low-vision aids coverage when filed within 9 monthsCPT

66920	Ophthalmic surgical code referenced for lookback
66930	Ophthalmic surgical code referenced for lookback
66940	Ophthalmic surgical code referenced for lookback
66982	Ophthalmic surgical code referenced for lookback
66983	Ophthalmic surgical code referenced for lookback
66984	Ophthalmic surgical code referenced for lookback
66988	Ophthalmic surgical code referenced for lookback
66989	Ophthalmic surgical code referenced for lookback
66991	Ophthalmic surgical code referenced for lookback

Accessory/component codeHCPCS

V2797

Vision supply, accessory and/or service component of another HCPCS vision code

Sphere and cylinder diopter ranges (representative V-codes)

V2100 (single vision sphere)plano to ±4.00 diopters (per lens)

V2101 (single vision sphere)±4.12 to ±7.00 diopters (per lens)

V2102 (single vision sphere)±7.12 to ±20.00 diopters (per lens)

V2103 (sphero-cylinder)sphere plano to ±4.00 d with cylinder .12 to 2.00 d (per lens)

Documentation, Authorization, and Billing Guidance

Prior Authorization

Prior authorization review is not required.

Prior authorization not required for covered services.

Note

Coverage Contingency

Coverage for contact lenses and corneal bandages is limited to therapeutic uses (e.g., as a corneal bandage to promote healing) and for aphakia/pseudoaphakia when policy criteria are met. Verify member benefits and Evidence of Coverage—if policy criteria are not met services may be billed to the member or covered by a standalone vision rider.

Coverage contingent on meeting policy criteria and member contract; check EOC or Subscriber Agreement.
If not covered under medical plan, check standalone vision plan or rider; absent rider member responsible for payment.

Clinical Background and Scope

Aphakia is defined in this policy as the absence of the crystalline lens of the eye due to surgical removal (e.g., cataract extraction without implantation of an intraocular lens), perforating wound/ulcer, or congenital anomaly. When an intraocular lens cannot be implanted or is not present, members may require corrective eyewear or contact lenses to restore functional vision.

The policy indicates that for aphakic members, covered therapeutic options include bifocal lenses in frames, separate frames with far and near lenses, or contact lenses for distance with companion near lenses in frames. Replacement lenses are allowed when medically necessary, and certain lens features (for example, anti-reflective coating, tints, oversize lenses, and UV protection) are covered when prescribed and medically necessary. Note that polycarbonate or other impact-resistant materials are restricted to members with functional vision in only one eye.

Key Terms

Aphakia definition

TermAphakia

DefinitionAbsence of the lens of the eye due to surgical removal (e.g., cataract surgery), perforating wound/ulcer, or congenital anomaly; may require eyeglasses or contact lenses when an IOL is not implanted.

Clinical noteIOLs are permanent artificial lenses implanted to replace the crystalline lens; aphakia occurs when an IOL cannot be safely placed.

Pseudophakia definition

TermPseudophakia

DefinitionCondition in which an intraocular lens (IOL) has been implanted to replace the natural lens, typically after cataract removal.

Clinical note

Policy Revision Timeline

2026-04provider_updateLatest

Policy referenced in Provider Update April 2026 (publication list includes April 2026).

2023-04provider_update

Policy referenced in Provider Update April 2023 (publication list includes April 2023).

2021-06provider_update

OpenPayer

Therapeutic Eyeglasses and Contact Lenses