CurrentCapital BluecrossPolicy MP 6.058

INTRAOCULAR LENSES, SPECTACLE CORRECTION AND IRIS PROSTHESIS

Defines medical necessity criteria for initial and replacement intraocular lens (IOL) implants, spectacle/contact lens correction for aphakia and pseudophakia, coverage exclusions for premium IOLs and certain spectacle customizations/low vision aids, and indications for iris prosthesis. Includes coding lists and benefit variation disclaimer for Capital Blue Cross products.

Policy Summary

PayerCapital Bluecross

PolicyINTRAOCULAR LENSES, SPECTACLE CORRECTION AND IRIS PROSTHESIS

Policy CodePolicy MP 6.058

Change TypeAdministrative coding and clinical benefit addition

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionDocument absence of the natural lens or anisometropia ≥3D with uncorrectable vision when requesting a standard monofocal IOL; verify benefits/prior authorization and use listed codes appropriately.

SourceLink

POLICY UPDATE CHANGES

Added code 66683 and removed codes 0616T, 0617T, 0618T effective 1/1/2025 (administrative update noted 12/11/2024).

Clinical benefit line added 01/19/2024 (administrative update).

4Iris prosthesis covered indications listed

>=3DAnisometropia threshold for IOL

MultiplePremium IOL types listed as not medically necessary

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Coverage Summary

This policy (MP 6.058) addresses medical necessity criteria for intraocular lenses (IOLs), spectacle/contact lens correction for aphakia and pseudophakia, and indications for iris prosthesis. Status: CURRENT. Effective date: 1/1/2025; Last review: 12/11/2024. The policy purpose is to define initial and replacement IOL criteria, specify covered spectacle/contact correction for aphakia/pseudophakia, list premium IOLs and certain lens customizations considered not medically necessary, and state indications for iris prosthesis. Benefit coverage and any limits vary by the member's certificate of coverage/benefits booklet and product-specific plan design; the policy does not guarantee that a service is a covered benefit under every member's plan.

Policy metadata and thresholds

Policy NumberMP 6.058

PayerCapital Blue Cross

Effective Date1/1/2025

Last Review2024-12-11

StatusCURRENT

Anisometropia threshold>= 3 diopters

Medical‑Necessity Criteria

Initial IOL Implant

A standard monofocal intraocular lens (IOL) implant is medically necessary when ALL of the following are met:

ALL of the following

The lens to be implanted is a standard monofocal intraocular lens (IOL)
AND the natural lens is absent due to ONE of:
- Following cataract extraction
- Trauma to the eye which has damaged the lens
- Congenital cataract

Coding

Not medically necessary - premium intraocular lens implantsHCPCS|CPTNot Covered

C1780	Intraocular lens, not otherwise specified (listed multiple times in document)
C1840	Replacement IOL (listed as associated procedure code in policy)
Q1004	Lens, intraocular, hydrophobic acrylic, presbyopia-correcting
Q1005	Lens, intraocular, hydrophobic acrylic, presbyopia-correcting (variant)
S0596	Insertion of presbyopia-correcting IOL (example) / miscellaneous code listed
V2787	Deluxe lens feature (listed among premium/custom features)
V2788	Reserved/code listed among premium features

Not medically necessary - spectacle customization and accessories (pseudophakia/aphakia)HCPCSNot Covered

V2745	Tinted lenses (as sunglasses in addition to prosthetic lens) - Not medically necessary
V2744	Photochromatic lenses - Not medically necessary (when additional to prosthetic lens)
V2760	Scratch resistant coating - Not medically necessary
V2761	Mirror coating - Not medically necessary
V2762	Polarization - Not medically necessary
V2781	Progressive lenses - Not medically necessary
V2784	Polycarbonate or similar material to decrease weight/thickness - Not medically necessary (except polycarbonate may be MN for single-eyed individuals)
V2782	High index glass/plastic - Not medically necessary
V2025	Deluxe frames - Not medically necessary
V2756	Eyeglass cases - Not medically necessary

Not medically necessary - low vision aidsHCPCSNot Covered

V2600-V2615	Low vision aids range listed as not medically necessary
V2610	Low vision aid example code listed
V2615	Low vision aid example code listed

Covered when medically necessary - intraocular lens implant (IOL)HCPCSCovered

V2630	Intraocular lens implant - covered when medically necessary
V2631	Intraocular lens implant variant
V2632	Intraocular lens implant variant

Covered when medically necessary - spectacle correction (eyeglasses) and contactsHCPCSCovered

V2105	Spectacle correction grouping header - covered when medically necessary
S0581	Spectacle-related code appearing in covered lists
V2020	Frame code appearing in covered lists
V2100-V2113	Range of lens codes (V2100-V2113) listed in covered mapping
V2202	Spectacle correction grouping header
V2210	Spectacle correction grouping header
V2220	Spectacle correction grouping header
V2305	Spectacle correction grouping header
V2313	Spectacle correction grouping header
V2410	Spectacle correction grouping header

1–10 of 13

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Covered when medically necessary - contactsHCPCSCovered

V2520	Contacts grouping header - covered when medically necessary
V2501-V2503	Contact lens code variants listed in covered mapping
V2510-V2513	Contact lens fitting/service codes listed
V2521-V2531	Contact lens mapping/result codes listed

Covered when medically necessary - Iris ProsthesisHCPCS|CPTCovered

C1839	Prosthetic iris implant - covered when medically necessary (listed with associated CPTs)
66683	Procedure code (CPT) associated with iris prosthesis; added effective 1/1/2025 per policy history
66999	Unlisted procedure, anterior segment of eye (associated with iris prosthesis placement)

Relevant ICD-10-CM Diagnosis Codes (examples listed)ICD-10

E10.36	Type 1 diabetes mellitus with diabetic cataract
E11.36	Type 2 diabetes mellitus with diabetic cataract
H21.89	Other specified disorders of iris and ciliary body
H25.011	Cortical age-related cataract, right eye
H25.012	Cortical age-related cataract, left eye
H25.013	Cortical age-related cataract, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
H52.31	Anisometropia

1–10 of 20

1/2

Provider Actions

Documentation Required

Demonstrate indication for IOL

When requesting a standard monofocal IOL, document that the natural lens is absent (for example, status post cataract extraction, lens-damaging trauma, or congenital aphakia) or document anisometropia of at least 3 diopters with vision uncorrectable by glasses or contact lenses. Acceptable indications include: post‑cataract extraction, trauma to the eye damaging the lens, and congenital aphakia.

Post‑cataract extraction
Trauma to the eye which has damaged the lens
Congenital aphakia

Documentation Required

Document necessity for replacement IOL

When requesting replacement of a previously implanted IOL, document the reason the existing IOL is ineffective or nonfunctional — specifically note an anatomical change, an inflammatory response, or mechanical failure.

Background

Background: When the natural lens is absent (aphakia) vision may be restored using spectacles (high‑power thick lenses), contact lenses, or by placing a permanent intraocular lens (IOL) inside the eye. IOL types described include standard monofocal IOLs (single fixed focal point), and premium IOLs such as toric (for astigmatism), multifocal (two focal points for distance and reading), and accommodative IOLs (designed to shift focus via ciliary body movement). The CustomFlex Artificial Iris Implant (HumanOptics AG) is identified as the only FDA‑approved standalone prosthetic iris; it is thin, foldable silicone, can be sized/colored for individual patients, and its use is restricted to practitioners who have completed required training/certification before ordering the device.

Evidence summary: Relevant guidance includes CMS references for intraocular and refractive lenses (National Coverage Determination 80.12 and Local Coverage Determination L33793). A Cochrane systematic review is cited for accommodative versus standard monofocal IOLs: Ong H, Evans J, Allan (Cochrane Database Syst Rev. 2014; CD009667).

Medicare Determinations

Name	Number / Type
Intraocular Lenses	80.12 / NCD
Refractive Lenses	L33793 / LCD

Revision History

2024-12-11coding_change

Administrative coding update: added code 66683 and removed codes 0616T, 0617T, 0618T; effective 1/1/2025. Policy statements unchanged (non-material).

2024-01-19administrative_update

Administrative update: clinical benefit line added. Policy statements unchanged (non-material).

Definitions

Definitions:

Aphakia — absence of the lens of the eye due to surgical removal, perforating wound/ulcer, or congenital anomaly.

Aniridia — an eye disorder in which the iris is malformed and often minimal in size; typically a bilateral condition.

Anisometropia — unequal refraction between a person’s eyes; a difference of >3 diopters is a clinically relevant threshold.

Intraocular Lens (IOL) — a synthetic artificial lens implanted inside the eye to replace the focusing power of the natural lens.

Policy Summary

PayerCapital Bluecross

PolicyINTRAOCULAR LENSES, SPECTACLE CORRECTION AND IRIS PROSTHESIS

Policy CodePolicy MP 6.058

Change TypeAdministrative coding and clinical benefit addition

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

On This Page

Lens subluxation/displacement

ALL of the following

Anisometropia of three diopters or greater>= 3 diopters
Vision is uncorrectable with the use of glasses or contact lenses
Standard monofocal IOL is used

Premium intraocular lens implants (examples listed) are not medically necessary for any indication

See policy for examples of presbyopia-correcting, astigmatism-correcting, and phakic IOLs

IOL for Anisometropia

Covered when ALL are met:

Anisometropia of three diopters or greater>= 3 diopters

Vision is uncorrectable with the use of glasses or contact lenses

Standard monofocal IOL is used

Replacement of Previously Implanted IOL

Replacement is medically necessary when ANY of the following render the previously implanted IOL ineffective or nonfunctional:

Anatomical change

Inflammatory response

Mechanical failure

Iris Prosthesis

Iris prosthesis may be considered medically necessary when ANY of the following indications are present:

Aniridia

Traumatic injury to the eye

Albinism (Achromasia)

Melanoma of the eye

Other indications: All other indications are considered investigational due to insufficient evidence

Spectacle/Contact Replacement for Pseudophakia

Covered when medically necessary:

One pair of eyeglasses or contact lenses is medically necessary after each cataract surgery with insertion of an IOL

If bilateral sequential cataract extractions occur without receiving eyeglasses/contact lenses between procedures, only one pair after the second surgery is medically necessary

If only new lenses (not new frames) are provided after surgery and frames existed, new frames are not covered later unless following subsequent cataract extraction in the other eye

Spectacle/Contact Correction for Aphakia - Initial

Medically necessary for the first pair when aphakia is congenital or following cataract removal without IOL:

Primary options: Bifocal lenses in frames

Primary options: Trifocal lenses in frames

Primary options: Lenses in frames for far vision AND lenses in frames for near vision

Primary options: Contact lens(es) for far vision (including binocular and monocular aphakia)

Additional lens options that may be considered medically necessary: Anti-reflective coating (V2750)

Additional lens options that may be considered medically necessary: Tinted lenses (V2744, V2745) unless used as sunglasses prescribed in addition to an untinted prosthetic lens

Additional lens options that may be considered medically necessary: Polycarbonate lenses (V2784, S0580) for individuals with functional vision in only one eye

Additional lens options that may be considered medically necessary: Oversize lenses (V2780)

Additional lens options that may be considered medically necessary: UV protection (V2755)

Premium IOLs

Not medically necessary for any indication because intended to reduce need for reading glasses:

Presbyopia-correcting IOLs (examples: Array Model SA40, ReZoom, AcrySof Restor, Tecnis Multifocal IOL, Tecnis Symfony, Tecnis Symfony Toric, Trulign, Toric IO, Crystalens Aspheric Optic)

Astigmatism-correcting IOLs (examples: AcrySof IQ Toric IOL, Tecnis Toric Aspheric IOL)

Phakic IOLs (examples: Artisan, Staar Visian ICL)

Replacement Lenses for Aphakia

Covered when medically necessary:

An additional pair of lenses (eyeglass or contact) is medically necessary each time the member's prescription changes

Refer to member's certificate of coverage/benefits booklet for limits

Prior Authorization

Benefit & preauthorization check

Before scheduling the service, verify the member's certificate of coverage/benefits booklet to confirm whether the procedure and related services are a covered benefit, to identify any benefit limits, and to determine if prior authorization is required under the member's specific plan.

Billing Rule

Coding consistency and mapping

Use the HCPCS/CPT/ICD‑10 codes listed in the coding section that are consistent with the performed procedure and diagnosis. Ensure coding and mapping are consistent with documentation and the member's benefit plan.

Identification of code does not guarantee coverage; coverage is determined by the member's benefit plan.

Documentation Required

Iris prosthesis training requirement (manufacturer/FDA)

For FDA‑restricted iris prosthesis devices (for example, the CustomFlex Artificial Iris), confirm the practitioner has completed the required manufacturer/FDA training and certification prior to ordering or implanting the device.