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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/Optometryhusky_health V2799 Coverage & Prior Auth Update | …
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    Currenthusky_healthPolicy N/A

    Vision item or service, miscellaneous (HCPCS V2799)

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    Govern prior authorization, medical necessity, coverage, and documentation requirements for miscellaneous vision items and services billed with HCPCS code V2799 for HUSKY Health (Connecticut Medicaid) providers.

    Policy Summary
    Payerhusky_health
    PolicyVision item or service, miscellaneous (HCPCS V2799)
    Policy CodePolicy N/A
    Change TypeClinical & administrative restructuring
    Effective DateNov 1, 2024
    Last ReviewJun 10, 2026
    Next Review DateN/A
    Key ActionSubmit a fully completed online authorization request (or Outpatient Prior Authorization Form) with clinical documentation and AAC/pricing when requesting coverage for items billed under V2799.
    SourceLink
    POLICY UPDATE CHANGES

    Not Medically Necessary section restructured to provide clinical rationale for customized lens features not being medically necessary and a separate section created for non-covered services; references updated.

    V2799HCPCS code addressed
    $95.81PA threshold (AAC >)
    Unilateral aphakia, keratoconus, corneal transplant, high anisometropiaMedically necessary for

    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.

    Scleral lenses
    Covered for

    Coverage and Medical Necessity Criteria

    Medically Necessary Indications

    Covered when ALL of the following are met (service-specific clinical criteria):

    Contact lenses for specific conditions: Contact lenses billed with V2799 are considered medically necessary when used for unilateral aphakia, keratoconus, corneal transplant, or high anisometropia; requests for contact lenses for other conditions will be reviewed on a case-by-case basis.

    Supported by chunks 2 and 3

    Scleral lenses are medically necessary when used to correct vision in individuals with irregular or distorted corneas due to keratoconus, post corneal transplant, post refractive surgery, corneal scarring, or ocular surface disease (e.g., severe dry eyes, graft-versus-host disease, Stevens-Johnson syndrome, ocular pemphigoid).

    Supported by chunk 3

    Customized lens features are considered not medically necessary because most ocular conditions can be adequately managed with standard lenses. Examples of customized features that are not covered include, but are not limited to, high‑index lenses, anti‑reflective lenses, and progressive bifocal lenses.

    Non‑medical accessories related to eyewear are also non‑covered as they do not meet the definition of medical necessity; examples include items such as eyeglass cleaners and eyewear cords/chains/retainers.

    The policy rationale is that the majority of refractive and other common ocular conditions can be effectively managed with standard spectacle lenses. Therefore, additional or customized lens options that primarily modify material, coating, or cosmetic/comfort characteristics—such as high‑index, anti‑reflective, or progressive bifocal features—are not considered medically necessary and are excluded from coverage unless a clear, documented medical indication justifies their use.

    Coding and Billing

    Covered HCPCS CodesHCPCSCovered
    V2799Vision item or service, miscellaneous
    inv-05: PA cost threshold
    PA cost thresholdActual acquisition cost (AAC) greater than $95.81 triggers prior authorization for HCPCS code V2799.
    Billing requirementV2799 must be billed at actual acquisition cost for medically necessary miscellaneous vision items and services not on the DSS Optician/Eyeglasses Fee Schedule.
    ScopeApplies to miscellaneous vision items and services, including contact lenses when medically necessary for conditions such as unilateral aphakia, keratoconus, corneal transplant, and high anisometropia.

    Provider Requirements and Prior Authorization

    Prior Authorization

    Prior authorization required for V2799 when AAC > $95.81

    Prior authorization is required for HCPCS code V2799 when the actual acquisition cost (AAC) is greater than $95.81; requests are reviewed based on submitted case‑specific information and medical necessity.

    • HCPCS code: V2799
    • PA threshold: AAC > $95.81
    Note

    Coverage is condition‑ and case‑specific; no step therapy specified

    Coverage decisions are individualized and based on the member’s clinical needs; no step therapy is specified in this policy. Contact lens requests for indications listed (e.g., unilateral aphakia, keratoconus, corneal transplant, high anisometropia) are evaluated case‑by‑case.

    • Coverage determinations follow the DSS definition of Medical Necessity and are case‑specific.
    • No step therapy requirement is stated in the policy.

    Background

    HCPCS code V2799 is used for miscellaneous vision items and services that are not listed on the standard fee schedule, and it includes contact lenses when such lenses are necessary to manage visual or ocular conditions that are not amenable to spectacles. Use of V2799 requires documentation supporting medical necessity and appropriate coding of the underlying diagnosis when applicable.

    Definitions

    inv-12: Medically Necessary / Medical Necessity definition
    DefinitionHealth services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition (including mental illness) in order to attain or maintain the individual's achievable health and independent functioning, consistent with Conn. Gen. Stat. § 17b-259b.
    StandardsMust be consistent with generally accepted standards of medical practice (credible peer-reviewed evidence, specialty society recommendations, views of practicing physicians, and other relevant factors).
    AppropriatenessClinically appropriate in type, frequency, timing, site, extent and duration and considered effective for the individual's condition.
    Not for convenienceNot primarily for the convenience of the individual or providers and not more costly than alternatives producing equivalent results.
    Policy Summary
    Payerhusky_health
    PolicyVision item or service, miscellaneous (HCPCS V2799)
    Policy CodePolicy N/A
    Change TypeClinical & administrative restructuring
    Effective DateNov 1, 2024
    Last ReviewJun 10, 2026
    Next Review DateN/A
    Key ActionSubmit a fully completed online authorization request (or Outpatient Prior Authorization Form) with clinical documentation and AAC/pricing when requesting coverage for items billed under V2799.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCoding and BillingProvider Requirements and Prior AuthorizationBackgroundDefinitions
    Documentation Required

    Submit completed prior authorization request and recent signed prescription

    Submit a fully completed authorization request via the online web portal or the Outpatient Prior Authorization Request Form, and include a signed prescription written within the past 6 months from an enrolled prescriber.

    • Fully completed authorization request (online portal or Outpatient Prior Authorization Request Form)
    • Signed prescription within the past 6 months from treating physician, APRN, optometrist, or PA enrolled in CMAP
    Documentation Required

    Include ICD‑10‑CM diagnosis code and supporting clinical documentation for specific contact lens indications

    For contact lenses requested for unilateral aphakia, keratoconus, corneal transplant, or high anisometropia, include the ICD‑10‑CM diagnosis code clearly entered on the authorization request and provide documentation from the treating vision provider supporting medical necessity.

    • Include ICD‑10‑CM diagnosis code on/entered in the authorization request for the listed indications
    • Provide supporting clinical documentation from the treating vision provider
    Denial Risk

    PA required for V2799 over the AAC threshold — missing PA or AAC documentation risks denial

    Failure to obtain prior authorization for HCPCS V2799 when the actual acquisition cost exceeds $95.81 may result in denial of the request; pricing information/invoice showing AAC must be submitted for review.

    • Provide pricing/invoice showing actual acquisition cost (AAC) with the request
    • PA required when AAC > $95.81 — lack of PA may lead to denial