Medically Necessary Contact Lens Clinical Criteria
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Defines diagnoses, clinical findings, documentation, and coding requirements for medically necessary or visually required contact lenses in Washington, with Medicare coverage hierarchy rules.
No material clinical or coverage changes in this revision.
Covered Diagnoses and Clinical Criteria
Keratoconus
Covered for keratoconus when all of the following are met.
Keratoconus requirements
Preferred corneal assessment
- Topography is performed.
- OCT is performed.
- Corneal mapping is performed.
- Keratometry is performed.
High Ametropia
Covered for high ametropia when all of the following are met.
High ametropia requirements
- The eyeglass prescription is at least -8.00 or at least +8.00 diopters.≥ -8.00 or ≥ +8.00 diopters
- Eyeglass best-corrected visual acuity is 20/40 or worse in either eye.20/40 or worse
- Visual acuity improves by 2 lines or more with contact lenses.2 lines or more
Anisometropia
Covered for anisometropia when the following criterion is met.
Aphakia
For Medicare members, aphakia is governed by the applicable Medicare coverage hierarchy.
Applicable Medicare National Coverage Determinations and Local Coverage Determinations take precedence over routine vision health-plan criteria and Davis Vision medically necessary criteria.
Aniridia
Covered for aniridia when the documented finding is present.
Irregular Astigmatism
Covered for irregular astigmatism when the following criterion is met.
Contact lenses are available under these criteria only for the diagnoses listed in the policy. Diagnoses not listed are not eligible for coverage under these criteria.
Covered Diagnosis Codes and Measurement Thresholds
| H18.60 | Keratoconus (Ectactic corneal dystrophy) |
| H18.601 | Keratoconus (Ectactic corneal dystrophy) |
| H18.602 | Keratoconus (Ectactic corneal dystrophy) |
| H18.603 | Keratoconus (Ectactic corneal dystrophy) |
| H18.61 | Keratoconus (Ectactic corneal dystrophy) |
| H18.611 | Keratoconus (Ectactic corneal dystrophy) |
| H18.612 | Keratoconus (Ectactic corneal dystrophy) |
| H18.613 | Keratoconus (Ectactic corneal dystrophy) |
| H18.62 | Keratoconus (Ectactic corneal dystrophy) |
| H18.621 | Keratoconus (Ectactic corneal dystrophy) |
| H52.10 | Myopia |
| H52.11 | Myopia |
| H52.12 | Myopia |
| H52.13 | Myopia |
| H52.00 | Hyperopia |
| H52.01 | Hyperopia |
| H52.02 | Hyperopia |
| H52.03 | Hyperopia |
| H52.20 | Astigmatism |
| H52.201 | Astigmatism |
| H52.31 | Anisometropia |
| H27.00 | Aphakia |
| H27.01 | Aphakia |
| H27.02 | Aphakia |
| H27.03 | Aphakia |
| Q13.0 | Aniridia |
| Q13.1 | Aniridia |
| Q13.2 | Aniridia |
| H52.211 | Irregular Astigmatism |
| H52.212 | Irregular Astigmatism |
| H52.213 | Irregular Astigmatism |
| H52.21 | Irregular Astigmatism |
Documentation, Billing, and Coverage Rules
Keratoconus Diagnostic Testing
For keratoconus (ectatic corneal dystrophy), document objective corneal evaluation before billing medically necessary contact lenses. Provide topography, OCT, or corneal mapping when available, along with keratometry.
- Preferred testing: topography, OCT, or corneal mapping.
- Also document keratometry.
- Applicable ICD-10-CM codes include H18.60, H18.601-H18.603, H18.61, H18.611-H18.613, H18.62, H18.621-H18.623, and H18.711-H18.713.
High Ametropia Measurements
For high ametropia, submit the complete eyeglass prescription, best-corrected visual acuity for each eye, and the documented visual-acuity improvement achieved with contact lenses.
- Record the prescription in diopters, including the applicable myopia, hyperopia, astigmatism, or degenerative-myopia diagnosis.
- Record eyeglass best-corrected visual acuity separately for the right and left eyes.
- Document contact-lens visual-acuity improvement in lines.
Refractive Measurements
Document the refractive measurements supporting anisometropia and irregular astigmatism, including the relevant intereye prescription difference, astigmatism amount, and principal-meridian relationship.
- Anisometropia: prescription difference between the right and left eyes is at least 3.00 diopters in any meridian; ICD-10-CM H52.31.
- Irregular astigmatism: 2.00 diopters of astigmatism in either eye, with principal meridians separated by less than 90 degrees; ICD-10-CM H52.211, H52.212, H52.213, or H52.21.
Aniridia Finding
Document aniridia when the iris is underdeveloped or absent.
- Applicable ICD-10-CM codes: Q13.0, Q13.1, and Q13.2.
Claim Documentation and Coding
Submit the appropriate contact-lens fitting code according to the current American Medical Association CPT definition. Describe all prescribed materials with the appropriate HCPCS Level II code under the current American Medical Association Healthcare Procedural Coding System definition; medically necessary claims remain subject to review and audit.
- Use the current AMA CPT contact-lens fitting definition.
- Describe each prescribed material with the appropriate HCPCS Level II code.
- Ensure claims are complete because all medically necessary services are subject to review and audit.
Diagnosis Must Be Listed
Medically necessary or visually required contact lenses are available only for diagnoses included in these clinical criteria. Verify that the billed diagnosis is one of the listed qualifying conditions.
- Listed diagnoses are keratoconus (ectatic corneal dystrophy), high ametropia, anisometropia, aphakia, aniridia, and irregular astigmatism.
- Coverage criteria do not imply or guarantee approval; verify coverage with the member’s plan.
- Requirements are valid for three months from the publication date and may change.
Unsupported block type: denial_risk singular?
Condition-Specific Clinical Findings
Document the condition-specific clinical findings required for the qualifying diagnosis. Objective findings must support keratoconus, anisometropia, or irregular astigmatism.
- Keratoconus: document topography, OCT, or corneal mapping when available, plus keratometry.
- Anisometropia: document a prescription difference of at least 3.00 diopters in any meridian between the two eyes.
- Irregular astigmatism: document 2.00 diopters in either eye, with principal meridians separated by less than 90 degrees.
Medicare Coverage Hierarchy
For Medicare members, apply coverage authorities in the required order before using routine vision or Davis Vision criteria.
- 1. Any applicable National Coverage Determination (NCD).
- 2. Any applicable Local Coverage Determination (LCD).
- 3. Health Plan criteria for routine vision.
- 4. Davis Vision Medically Necessary clinical criteria.
- For aphakia, LCD L33793 supersedes the Davis Vision criteria for Medicare services performed on or after July 1, 2016.
Policy Scope
This policy addresses medically necessary or visually required contact lenses for selected corneal, refractive, lens, iris, and low-vision conditions. Covered diagnosis categories include keratoconus, high ametropia, anisometropia, aphakia, aniridia, and irregular astigmatism. Low-vision services may include evaluation, diagnosis, prescription of visual aids, and follow-up by an eye-care professional specializing in low-vision rehabilitation.
Key Terms
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