ModifiedIndiana Department of InsurancePolicy PROMOD00051

Vision Services

Customize your policy alerts

Sign up for Indiana Department of Insurance Policy PROMOD00051 alerts

Get alerted when Policy PROMOD00051 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage, prior authorization, benefit limits, billing, reimbursement, and medical-necessity requirements for vision services provided to Indiana Health Coverage Programs members under fee-for-service.

Policy Summary

PayerIndiana Department of Insurance

PolicyVision Services

Policy CodePolicy PROMOD00051

Change TypeModified

Effective DateSeptember 1, 2023

Next Review DateNot specified

Key ActionObtain prior authorization before providing Retisert, Yutiq, or Luxturna.

SourceLink

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.

ModifiedIndiana Department of InsurancePolicy PROMOD00051

Vision Services

Customize your policy alerts

Sign up for Indiana Department of Insurance Policy PROMOD00051 alerts

Get alerted when Policy PROMOD00051 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerIndiana Department of Insurance

PolicyVision Services

Policy CodePolicy PROMOD00051

Change TypeModified

Effective DateSeptember 1, 2023

Next Review DateNot specified

Key ActionObtain prior authorization before providing Retisert, Yutiq, or Luxturna.

SourceLink

POLICY UPDATE CHANGES

Version 7.0 added two drugs requiring prior authorization in the Prior Authorization for Vision Services section.

Version 7.1 added a title-page note directing providers to IHCP Bulletin BT2026155 for updates concerning specific vision-service billing requirements.

The policy requires the most current MSRP or cost invoice not older than two years for manually priced deluxe frames effective January 7, 2024.

3Vision medications requiring prior authorization

1/12 monthsRoutine eye exam limit under age 21

1/2 yearsRoutine eye exam limit age 21 and older

1 pair/12 monthsEyeglass limit under age 21

1 pair/5 yearsEyeglass limit age 21 and older

1/dayVision therapy limit

Coverage Criteria

Eyeglasses

Eyeglasses are covered when the applicable frequency limit and at least one minimum prescription criterion are met.

Eyeglasses coverage

Minimum prescription criterion: The initial prescription or qualifying subsequent change is at least 0.75 diopters in one eye for members age 6 through 42; at least 0.50 diopters in one eye for members age 42 or older; or the axis change is at least 15 degrees.0.75 diopters; 0.50 diopters; or 15-degree axis change

Polycarbonate Lenses

HCPCS V2784 is covered when a corrective lens is medically necessary and one or more ocular-protection criteria are met.

Polycarbonate lens coverage

Qualifying ocular condition: The member has carcinoma in one eye with a corrective-lens need in the healthy eye; only one eye requiring correction; prior eye surgery with continued corrective-lens need; retinal detachment or postsurgical retinal detachment with refractive error; cataract or post-cataract surgery with refractive error; low vision or legal blindness in one eye with normal or near-normal vision in the other; or another qualifying intractable ocular condition requiring protection of remaining healthy vision.At least one condition
In the applicable circumstances, one or both eyes must be affected by an intractable ocular condition, and the patient chart must support medical necessity.

Deluxe Frames

V2025 deluxe frames are covered when a more expensive frame is medically necessary.

Medically necessary deluxe frame: A more expensive frame is medically necessary because of a facial deformity or anomaly, special modification such as a ptosis crutch, allergy to standard frame materials, special-size need for an infant or child, or another supported medical circumstance.Medical necessity documented

Submit medical-necessity documentation and the manufacturer's suggested retail price or cost invoice. Reimbursement is limited to 75% of MSRP or 120% of cost invoice.

Contact Lenses

Contact lenses are covered when medically necessary.

Contact-lens coverage: Contact lenses are medically necessary.Medical necessity

Maintain supporting documentation in the patient's medical record for postpayment review.

Orthoptic, Pleoptic, and Vision Therapy

Vision therapy is covered under CPT 92065 when all ordering, treatment, qualification, supervision, and documentation requirements are met.

Vision therapy coverage: A physician or optometrist orders the service; the record contains a diagnosis, treatment plan, and need for continued treatment; the service is performed by an optometrist, physician, or trained or certified staff; staff perform orthoptic or pleoptic training under direct supervision; and the supervising provider documents the treatment plan and reevaluations and cosigns staff documentation.1 unit or visit per day

Direct supervision requires the supervising physician or optometrist to be physically available at the time and place of service.

Medically Necessary Contact Lenses

Contact lenses are covered when medically necessary, including but not limited to the following circumstances.

Medical necessity examples: The member has a severe facial deformity and is physically unable to wear eyeglasses; or the member has severe allergies to all frame materials.

These examples are not exhaustive.

Orthoptic, Pleoptic, and Vision Therapy

Coverage requires all of the following criteria.

Vision therapy requirements

Order and clinical plan: A physician or optometrist orders the vision therapy services, and the physician or optometrist documents a diagnosis, treatment plan, and need for continued treatment in the member's medical record.
Qualified performance and supervision: An optometrist, physician, or supervised staff certified or trained to provide the services performs the therapy. Staff trained or certified in vision training perform orthoptic and pleoptic training only under the direct supervision of an optometrist or physician who is physically available at the time and place of service.
Documentation and cosignature: Only the supervising optometrist or physician documents the treatment plan and reevaluations, and documentation of directly supervised services rendered by staff is cosigned by the supervising optometrist or physician.

Intraocular Stents

Coverage requires the intraocular stent to be inserted in conjunction with cataract surgery.

Intraocular stent coverage: The intraocular stent is inserted in conjunction with cataract surgery, and the claim includes a cataract surgery code.

New Technology Intraocular Lenses

Coverage requires the NTIOL to be billed in conjunction with cataract surgery.

NTIOL coverage: The lens is a CMS-identified new technology intraocular lens and is billed in conjunction with a cataract surgery code.

For procedure code C1780, submit an MSRP or cost invoice.

Vitrectomy Medical Necessity

Diagnoses that may support medical necessity for vitrectomy as a sight-saving procedure include the following.

Sight-saving vitrectomy indications: The member has vitreal hemorrhage, retinal detachment, scarring or fibrosis of the vitreous, or proliferative retinopathy.

The listed diagnoses are not exhaustive. Maintain documentation supporting medical necessity in the member's medical record.

Retisert

Retisert may be considered medically necessary only when all criteria are met.

Retisert criteria

Age: The member is 12 years of age or older.>= 12 years
Diagnosis: The member has chronic noninfectious uveitis affecting the posterior segment of the eye.
Prior treatment or justification: The member previously tried and failed conventional treatments, including corticosteroid therapy, methotrexate, mycophenolate, azathioprine, cyclosporine, tacrolimus, cyclophosphamide, or adalimumab; or medical justification is provided for using Retisert over these therapies.

Yutiq

Yutiq may be considered medically necessary only when all criteria are met.

Yutiq criteria

Age: The member is 18 years of age or older.>= 18 years
Diagnosis: The member has chronic noninfectious uveitis affecting the posterior segment of the eye.
Prior treatment or justification: The member previously tried and failed conventional treatments, including corticosteroid therapy, methotrexate, mycophenolate, azathioprine, cyclosporine, tacrolimus, cyclophosphamide, or adalimumab; or medical justification is provided for using Yutiq over these therapies.

Luxturna

Luxturna is considered medically necessary when all criteria are met.

Luxturna criteria

Age: The member is greater than 12 months of age.> 12 months
Diagnosis and genetics: The member has confirmed biallelic RPE65 mutation-associated retinal dystrophy, such as Leber's congenital amaurosis, retinitis pigmentosa, or early-onset severe retinal dystrophy, and genetic testing documents biallelic RPE65 mutations.
Retinal viability: The treating physician determines that the member has sufficient viable retinal cells.
Qualified provider:

Noncovered lens features include decorative designs, lenses larger than 61 millimeters unless medical necessity is documented, fashion or gradient tints, sunglasses, and photochromatic lenses. Tint numbers 1 and 2 may be covered when medically necessary.

Progressive lenses, transitional lenses, antireflective coating, and tint numbers other than 1 and 2 are not covered as upgrades. When a member selects an upgrade, the provider may bill the basic lens V code to IHCP and bill the upgrade to the member only when appropriate advance notice of noncoverage was provided and a separate procedure code exists.

IHCP does not cover any portion of a deluxe or fancy frame unless it is medically necessary. When a member selects a deluxe-frame upgrade without medical necessity, the entire frame is noncovered. The provider may bill the member only after providing advance written notice of noncoverage and obtaining the member's signature; in that situation, submit only the lens claim to IHCP.

Vision-training services under CPT 92065 are noncovered by Medicare. For members who are dually eligible for Medicare and full Medicaid coverage, providers may bill the services directly to IHCP on a professional claim without first submitting the claim to Medicare.

Vitrectomy services billed with a corneal transplant on the same eye are denied when the vitrectomy is performed to restore the anterior chamber. Vitrectomy performed through the pars plana or by the open-sky technique with a corneal transplant is paid under the applicable surgical payment guidelines.

Retisert and Yutiq are covered for chronic posterior uveitis when their respective medical-necessity and prior-authorization requirements are met, but neither drug should be billed for diabetic macular edema.

A deluxe or fancy frame selected by the member without medical necessity is not covered. If the provider gives advance written notice of noncoverage and obtains the member's signature before billing, the entire frame may be billed to the member; otherwise, the frame is not billable as a covered service.

Coding, Limits, and Reimbursement

Diagnostic ServicesCPTCovered

95930

Visual evoked potential (VEP) testing central nervous system, checkerboard or flash only

Refractive ServicesCPTCovered

92015

Determination of refractive state

Covered Tint CodesHCPCSCovered

V2745 U1	Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens; rose 1 or 2, plastic
V2745 U2	Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens; rose 1 or 2, glass

Polycarbonate LensesHCPCSCovered

V2784

Lens, polycarbonate or equal, any index, per lens

FramesHCPCSCovered

V2020	Frames, purchases
V2025	Deluxe frame

Eyeglass Repair and Replacement ModifiersModifier

U8	Modifier required for qualifying repair or replacement of eyeglasses before the established frequency limit
SC	Modifier required for replacement lenses or frames before the frequency limit due to a qualifying prescription change

Contact LensesCPTCovered

92310	Contact-lens prescription service
92311	Contact-lens prescription service
92312	Contact-lens prescription service
92313	Contact-lens prescription service
92314	Contact-lens prescription service
92315	Contact-lens prescription service
92316	Contact-lens prescription service
92317	Contact-lens prescription service
92325	Later modification of successfully fitted extended-wear contact lenses
92326	Later replacement of successfully fitted extended-wear contact lenses

Orthoptic or Pleoptic Training and Vision TherapyCPTCovered

92065

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Contact Lens CPT CodesCPTCovered

92310 through 92317	Appropriate CPT codes for prescription of contact lenses, including fitting, instruction and training, and incidental revision during the training period.
92325	Later modification of successfully fitted extended-wear lenses.
92326	Replacement of successfully fitted extended-wear lenses.

Vision Training CPT CodeCPTCovered

92065

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation.

Intraocular Lens CodeHCPCSCovered

C1780

Procedure code requiring submission of an MSRP or cost invoice for an intraocular lens.

Retisert HCPCS CodeHCPCSCovered

J7311

Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg.

Yutiq HCPCS CodeHCPCSCovered

J7314

Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg.

Luxturna HCPCS CodeHCPCSCovered

J3398

Injection, voretigene neparvovec-rzyl, 1 billion vector genomes.

Triamcinolone Acetonide HCPCS CodesHCPCSCovered

J3299	Injection, triamcinolone acetonide, suprachoroidal (Xipere), 1 mg.
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg.
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg.

Required Drug IdentifiersNDC

NDC	Appropriate National Drug Code required with the applicable ophthalmologic drug HCPCS code.

Routine eye examination: members under 21

Member ageUnder 21 years of age

Covered frequencyOne eye examination per 12-month period

More frequent careRequires documentation of medical necessity maintained in the provider’s office and is subject to postpayment review and audit

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Vision Services Requiring Prior Authorization

Prior authorization is required for specified vision services. Obtain PA before furnishing or billing these services when applicable.

Blepharoplasty for a significant obstructive vision problem
Prosthetic devices other than eyeglasses
Reconstruction or plastic surgery
Yutiq (fluocinolone acetonide intravitreal implant)
Retisert (fluocinolone acetonide intravitreal implant)
Luxturna (voretigene neparvovec-rzyl)

Prior Authorization

Retisert Prior Authorization

Retisert requires prior authorization and may be medically necessary only when the member meets the age, diagnosis, and conventional-treatment requirements. Do not bill it for diabetic macular edema.

Policy Scope and Vision Services

This policy addresses vision services for Indiana Health Coverage Programs members, including eye examinations, refractive and diagnostic services, eyeglasses, contact lenses, vision therapy, ophthalmologic surgeries, and selected ophthalmologic drugs. Coverage generally depends on medical necessity, member age, benefit-frequency limits, applicable prescription criteria, and provider licensure or supervision requirements.

Definitions

Ophthalmologist

Professional typeLicensed medical physician or osteopathic physician

Primary qualificationAbility and credentials to perform surgical procedures on the eye and related structures

Practice requirementOphthalmology services must be provided within the scope of the physician’s licensure

Optometrist

Professional typeLicensed professional

Training and servicesTrained to examine eyes and vision and to prescribe and fit lenses

Clinical scope

Policy Summary

PayerIndiana Department of Insurance

PolicyVision Services

Policy CodePolicy PROMOD00051

Change TypeModified

Effective DateSeptember 1, 2023

Next Review DateNot specified

Key ActionObtain prior authorization before providing Retisert, Yutiq, or Luxturna.

SourceLink

On This Page

Luxturna is prescribed and administered by an ophthalmologist or retinal surgeon with experience providing subretinal injections.

Prior gene therapy: The member has not previously received RPE65 gene therapy in the intended eye.None previously in intended eye

Dose: The dose does not exceed 0.3 mL per eye, equivalent to two vials total.<= 0.3 mL per eye; two vials total

Routine eye examination: members 21 and older

Member age21 years of age and older

Covered frequencyOne eye examination every two years

More frequent careRequires documentation of medical necessity maintained in the provider’s office and is subject to postpayment review and audit

Eyeglasses: members under 21

Member ageUnder 21 years of age

Covered frequencyOne pair of eyeglasses per 12-month period

Additional requirementApplicable minimum prescription criteria must also be met

Eyeglasses: members 21 and older

Member age21 years of age or older

Covered frequencyOne pair of eyeglasses every five years

Additional requirementApplicable minimum prescription criteria must also be met

Minimum prescription: ages 6 through 42

Member age6 years of age through age 42

Minimum prescription0.75 diopters in at least one eye

Applies toAn initial prescription or a minimum change for a subsequent pair of glasses

Minimum prescription: age 42 and older

Member age42 years of age and older

Minimum prescription0.50 diopters in at least one eye

Applies toAn initial prescription or a minimum change for a subsequent pair of glasses

Qualifying axis change

Qualifying changeAxis change

Minimum thresholdAt least 15 degrees

Coverage contextQualifies as a minimum prescription criterion for an initial or subsequent pair of eyeglasses

Lens size

Size thresholdLarger than 61 millimeters

Coverage statusNoncovered

ExceptionCovered only when medical necessity is documented

Deluxe-frame reimbursement

Procedure codeV2025 — Deluxe frame

MSRP reimbursement limitUp to 75% of the manufacturer’s suggested retail price

Cost-invoice reimbursement limitUp to 120% of the cost invoice

MSRP or cost-invoice age

Required documentMost current MSRP or cost invoice

Maximum document ageNot older than two years from the date of service

Effective dateJanuary 7, 2024, for manually priced items

Vision therapy frequency

Applicable serviceVision training therapies billed under CPT 92065

Daily limitOne unit or visit per day

Coverage conditionMedical necessity and the policy’s ordering, supervision, qualification, and documentation criteria must be met

CPT 92065 daily limit

CPT code92065 — Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Unit limitOne unit per day

Visit limitOne visit per day

Retisert dose limit

HCPCS codeJ7311 — Retisert

Dose limitOne implant per date of service

Billing identifierThe applicable National Drug Code must be billed with J7311

Luxturna dose limit

HCPCS codeJ3398 — Luxturna

Per-eye limitNo more than 0.3 mL per eye

Total vial limitTwo vials total

J3300 reimbursement limit

HCPCS codeJ3300 — Preservative-free triamcinolone acetonide, 1 mg

Reimbursement limit40 mg per date of service

Wastage documentationDocument both the amount administered and the amount discarded when unused product is billed

Member is at least 12 years old.

Diagnosis is chronic, noninfectious uveitis affecting the posterior segment of the eye.

HCPCS J7311 is limited to one implant per date of service and must include the appropriate NDC.

Submit records supporting the diagnosis, eligibility, treatment history or medical justification, and PA.

Prior Authorization

Yutiq Prior Authorization

For dates of service on or after December 9, 2022, Yutiq requires prior authorization and must meet the stated age and diagnosis criteria. Do not bill it for diabetic macular edema.

Member is at least 18 years old.
Diagnosis is chronic, noninfectious uveitis affecting the posterior segment of the eye.
HCPCS J7314 must include the appropriate NDC.
Submit records supporting eligibility, diagnosis, treatment history or medical justification, and PA.

Prior Authorization

Luxturna Prior Authorization

Luxturna requires prior authorization and supporting clinical and genetic documentation. Confirm every eligibility, provider, treatment, and dosing requirement before administration.

Member is older than 12 months.
Confirmed biallelic RPE65 mutation-associated retinal dystrophy is documented, with genetic testing confirming the mutations.
Treating physician confirms sufficient viable retinal cells.
Treatment is prescribed and administered by an ophthalmologist or retinal surgeon experienced with subretinal injections.
Member has not previously received RPE65 gene therapy in the intended eye.
Dose does not exceed 0.3 mL per eye (two vials total).
Bill HCPCS J3398 with the appropriate NDC; in an inpatient setting, bill the drug separately as a professional claim.

Step Therapy

Conventional-Treatment Failure

For Retisert and Yutiq, document failure of conventional treatment or provide medical justification for using the implant instead of those therapies.

Conventional treatments include corticosteroid therapy, methotrexate, mycophenolate, azathioprine, cyclosporine, tacrolimus, cyclophosphamide, and adalimumab.
Retisert and Yutiq require documentation of prior failure or a clinical justification for bypassing these treatments.

Documentation Required

Eye-Examination Documentation

When an eye examination or related care exceeds the routine frequency limit, maintain documentation in the provider’s office supporting medical necessity. The record is subject to postpayment review and audit.

Under age 21: routine examination limited to one per 12-month period.
Age 21 and older: routine examination limited to one every two years.
If counseling and coordination of care dominate the service, document total encounter time and a synopsis of the counseling and coordination activities.

Billing Rule

VEP Diagnosis Support

Bill CPT 95930 for visual evoked potential testing only with one of the diagnosis codes listed for the service in Vision Services Codes.

Applies to provider specialty 180 (optometrists).
Verify that the diagnosis code is an approved code before submitting the claim.

Documentation Required

Eyeglass Repair Support

To bill eyeglass repair before the member’s established frequency limit, use modifier U8 and retain records substantiating the need for repair.

Maintain the supporting documentation in the member’s medical record.
Modifier U8 indicates that the required documentation is on file.

Documentation Required

Eyeglass Replacement Support

Replacement eyeglasses or components must be medically necessary and supported in the medical record. Early replacement for loss, theft, or damage beyond repair also requires a signed member statement describing what happened.

Use modifier U8 for replacement before the frequency limit due to loss, theft, or damage beyond repair.
Use modifier SC for early replacement due to a qualifying prescription change under 405 IAC 5-23-4(7).
Document the need for replacement frames and/or lenses; either modifier represents that the documentation is on file.

Documentation Required

Polycarbonate Lens Documentation

Before billing HCPCS V2784, confirm that a corrective lens is medically necessary and that the member meets at least one qualifying ocular-protection criterion. Patient charts must support medical necessity.

Qualifying circumstances include carcinoma in one eye with a corrective-lens need in the healthy eye; a single eye requiring correction; post-eye surgery with continued corrective-lens need; retinal detachment or postsurgical retinal detachment with refractive-error correction; cataract or post-cataract surgery with refractive-error correction; or low vision/legal blindness in one eye with normal or near-normal vision in the other.
Other conditions may qualify only when an intractable ocular condition affects one eye and the polycarbonate lens protects the remaining vision of the healthy eye.
One or both eyes must be affected by an intractable ocular condition, and the lens must be medically necessary to correct a refractive error.

Documentation Required

Deluxe-Frame Documentation

Claims for HCPCS V2025 must include documentation supporting medical necessity for the deluxe frame, along with a current MSRP or cost invoice and the applicable charges.

Examples include facial deformity or anomaly, special modifications such as a ptosis crutch, allergy to standard frame materials, or special-size frames for an infant or child.
Effective January 7, 2024, the MSRP or cost invoice must be no older than two years from the date of service.
Reimbursement is up to 75% of MSRP or 120% of the cost invoice; do not bill the member above the IHCP reimbursement.

Documentation Required

Contact-Lens Documentation

Maintain medical-record documentation supporting contact-lens medical necessity for postpayment review, even though documentation is not required to accompany the claim.

Examples include severe facial deformity preventing eyeglass wear and severe allergy to all frame materials.
CPT 92310 through 92317 include fitting, wearer instruction and training, and incidental revision during training; do not bill those services separately.

Documentation Required

Vision-Therapy Documentation

Maintain a complete medical record for CPT 92065 vision therapy services. The record must establish medical necessity, ordering, treatment planning, continued need, qualified performance, and required supervision.

A physician or optometrist must order all vision therapy services.
The physician or optometrist must document the diagnosis, treatment plan, and need for continued treatment.
Services may be performed by an optometrist, physician, or certified or trained supervised staff.
Only the supervising optometrist or physician may document the treatment plan and reevaluations.
Directly supervised staff services must be cosigned by the supervising optometrist or physician.
CPT 92065 is limited to one unit or visit per day.

Billing Rule

Date-of-Service Documentation

Use the actual date on which the vision service was supplied, dispensed, or rendered. For eyeglasses, report the date the member received the glasses.

All claims must include a date of service.
Do not substitute an order, billing, or dispensing-preparation date for the actual service-delivery date.

Documentation Required

Contact-Lens Medical-Necessity Records

Contact-lens medical-necessity records must be retained in the patient’s medical record for postpayment review, although they do not need to accompany the claim.

Document the covered condition and why eyeglasses cannot be worn or are not appropriate.
Covered examples include severe facial deformity preventing eyeglass wear and severe allergy to all frame materials.

Documentation Required

Vision Therapy Documentation

For vision therapy, retain the order, diagnosis, treatment plan, continued-treatment rationale, treatment documentation, qualifications, supervision, and required cosignatures in the medical record.

The service must be ordered by a physician or optometrist.
Direct supervision requires the supervising physician or optometrist to be physically available at the time and place of service.
Only the supervising provider documents treatment plans and reevaluations; supervised staff documentation must be cosigned.

Documentation Required

Ophthalmologic Surgery Records

Maintain medical-record documentation supporting medical necessity for every ophthalmologic surgery.

Use the Surgical Services module for general surgical billing and reimbursement requirements.

Billing Rule

NTIOL Invoice

Submit the required MSRP or cost invoice with procedure code C1780 for an NTIOL claim.

The invoice supports the billed NTIOL cost or MSRP.
NTIOLs must be billed with a cataract surgery code and, for applicable ASC claims, on a separate professional claim using the facility’s DME NPI.

Documentation Required

Vitrectomy Records

Maintain documentation supporting the medical necessity of vitrectomy, including the sight-saving diagnosis and operative circumstances.

Potential supporting diagnoses include vitreous hemorrhage, retinal detachment, vitreous scarring or fibrosis, and proliferative retinopathy.
Ensure the claim accurately identifies pars plana, open-sky, anterior-chamber restoration, or combined procedures.

Billing Rule

Drug Coding and Clinical Support

For Retisert, Yutiq, and Luxturna, submit the appropriate NDC and retain the clinical records that support prior authorization, eligibility, diagnosis, treatment history, and dosing.

J7311 (Retisert), J7314 (Yutiq), and J3398 (Luxturna) require the appropriate NDC.
Records must support the applicable diagnosis, genetic or retinal findings, age, prior treatment or gene-therapy history, provider qualifications, and dose.

Documentation Required

Triamcinolone Wastage Documentation

When billing preservative-free triamcinolone wastage, document both the amount administered and the amount discarded in the member’s medical record.

J3300 reimbursement is limited to 40 mg per date of service.
For single-dose 40 mg vials, the entire vial may be billed when less than 40 mg is administered and the balance is discarded.

Prior Authorization

Required Prior Authorization

Obtain prior authorization before billing a covered vision service designated as requiring PA.

Blepharoplasty for significant obstructive vision problems
Prosthetic devices other than eyeglasses
Reconstruction or plastic surgery
Yutiq, Retisert, and Luxturna

Denial Risk

Unsupported Examination Frequency

Do not exceed routine eye-examination frequency limits without documentation supporting medical necessity. Unsupported extra examinations may be subject to postpayment review, audit, or denial.

Under age 21: one examination per 12 months.
Age 21 and older: one examination every two years.
Maintain documentation when more frequent examination or care is medically necessary.

Denial Risk

Eyeglass Criteria or Frequency Not Met

Eyeglasses are covered only when the minimum prescription criteria and applicable frequency limits are met.

Under age 21: one pair per 12 months; age 21 and older: one pair every five years.
Ages 6 through 42: at least 0.75 diopters in one eye, for an initial or qualifying subsequent prescription.
Age 42 and older: at least 0.50 diopters in one eye, for an initial or qualifying subsequent prescription.
Alternatively, an axis change of at least 15 degrees must be documented.

Denial Risk

Noncovered Lens Features

Do not bill noncovered lens features to IHCP. A member-selected upgrade may be billed to the member only when advance notice of noncoverage is provided and a separate procedure code exists.

Noncovered features include decorative designs, lenses larger than 61 millimeters unless medically necessary, fashion or gradient tints, sunglasses, and photochromatic lenses.
Tint numbers 1 and 2 are covered subject to medical necessity and applicable coding.
If the member chooses progressive, transitional, antireflective, or other noncovered upgrades, bill the basic lens V code to IHCP and separately bill only an eligible upgrade portion.

Denial Risk

Polycarbonate Criteria Not Met

HCPCS V2784 is not payable unless a corrective lens is medically necessary and the member meets a qualifying ocular-protection criterion. Unsupported polycarbonate use may be denied or recouped on postpayment review.

The lens must protect remaining vision associated with an intractable ocular condition and correct a refractive error.
Qualifying conditions include the specified single-eye, carcinoma, postsurgical, retinal-detachment, cataract, low-vision/legal-blindness, or similarly documented ocular-protection circumstances.
Patient charts must support medical necessity.

Denial Risk

Nonmedically Necessary Frame Upgrade

IHCP does not cover a deluxe or fancy frame without medical necessity. If the member elects a nonmedically necessary upgrade, the entire frame is noncovered.

The provider may bill the frame to the member only after proper advance notice of noncoverage and the member’s signature.
When billing a nonmedically necessary upgrade, submit only the lens claim to IHCP.
Do not bill the member for amounts above IHCP reimbursement when a frame is covered.

Denial Risk

Vision Therapy Requirements Not Met

Vision therapy is payable only when the ordering, treatment, qualification, supervision, documentation, and unit-limit requirements are satisfied.

A physician or optometrist must order the service and document the diagnosis, treatment plan, and continued need.
The provider or staff must be qualified; trained or certified staff require direct supervision by a physically available physician or optometrist.
The supervising provider must document treatment plans and reevaluations, and cosign staff-rendered service documentation.
CPT 92065 is limited to one unit or visit per day.

Denial Risk

Vision Therapy Criteria Not Met

Do not submit CPT 92065 when complete coverage criteria and supporting records are absent. The record must demonstrate medical necessity from the order through supervised treatment and reevaluation.

Required elements are a physician or optometrist order; diagnosis; treatment plan; continued-treatment rationale; qualified personnel; direct supervision where staff perform the service; supervising-provider documentation; and staff-documentation cosignature.
Vision therapy services are billed under CPT 92065 and are limited to one unit or visit per day.
For dually eligible members, these Medicare-noncovered services may be billed directly to IHCP on a professional claim.

Denial Risk

Stent Billed Without Cataract Surgery

An intraocular stent claim must include a cataract surgery code. A stent billed without the associated cataract surgery code is not payable.

Use an applicable cataract surgery code identified in Vision Services Codes.

Denial Risk

NTIOL Requirements Not Met

NTIOLs are covered only when billed with a cataract surgery code and the required claim, invoice, and provider details.

For ASC-rate facilities, use the physician’s cataract-surgery CPT code and appropriate revenue code on the institutional claim.
Submit the NTIOL on a separate professional claim using the facility’s DME NPI.
Submit an MSRP or cost invoice with C1780.

Denial Risk

Nonpayable or Incorrectly Coded Vitrectomy

Vitrectomy payment depends on accurate technique and diagnosis coding. Services may be denied, bundled, or incorrectly reimbursed when the claim does not reflect the actual procedure.

Vitrectomy billed with a corneal transplant on the same eye is denied when performed to restore the anterior chamber.
Pars plana or open-sky vitrectomy with cataract extraction or corneal transplant is processed under the applicable multiple-surgery guidelines.
Anterior-chamber restoration may be included in the cataract procedure; pars plana vitrectomy and photocoagulation billed separately must be combined and coded appropriately.

Denial Risk

Retisert Outside Covered Indication

Retisert is not covered for diabetic macular edema. For its covered indication, prior authorization and all clinical criteria must be met.

Covered indication: chronic, noninfectious posterior uveitis.
Member must be at least 12 years old.
Document prior failure of conventional treatments or medical justification for Retisert instead.
Bill no more than one J7311 implant per date of service and include the appropriate NDC.

Denial Risk

Yutiq Outside Covered Indication

Yutiq is not covered for diabetic macular edema. For dates of service on or after December 9, 2022, prior authorization and all clinical criteria must be met.

Covered indication: chronic, noninfectious posterior uveitis.
Member must be at least 18 years old.
Document prior failure of conventional treatments or medical justification for Yutiq instead.
Bill J7314 with the appropriate NDC.

Denial Risk

Luxturna Criteria Not Met

Do not administer or bill Luxturna unless prior authorization and every eligibility, genetic, retinal, provider, treatment-history, and dosing requirement are documented.

Member is older than 12 months and has confirmed biallelic RPE65 mutation-associated retinal dystrophy.
Genetic testing confirms biallelic RPE65 mutations and the treating physician confirms sufficient viable retinal cells.
An experienced ophthalmologist or retinal surgeon must administer subretinal injections.
No prior RPE65 gene therapy may have been given in the intended eye; dose is limited to 0.3 mL per eye (two vials total).
Bill J3398 with the appropriate NDC; bill the drug separately as a professional claim when delivered inpatient.

Diagnoses and treats visual problems or impairment within the scope of licensure

Direct supervision

Supervising professionalSupervising physician or optometrist

Physical-availability standardThe supervisor must be physically available

When and whereAt the time and place where vision-therapy services are rendered

New technology intraocular lenses (NTIOLs)

TermNew technology intraocular lenses (NTIOLs)

DesignationIdentified by the Centers for Medicare & Medicaid Services (CMS)

Basis for designationSuperior to other intraocular lenses in the same category because of a demonstrated decrease in postoperative complications

Vitrectomy

ProcedureVitrectomy

What is removedThe vitreous humor

When performedWhen the vitreous humor is diseased or damaged

RPE65-associated inherited retinal dystrophy

ConditionRPE65-associated inherited retinal dystrophy

Disease typeInherited retinal dystrophies

Genetic causeMutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene