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Refractive Lenses

Refractive lenses are covered when they are used to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence.

Coverage Indications

Diagnoses covered are:

  • Pseudophakia (ICD-9 V43.1)
  • Aphakia (ICD-9 379.31), and
  • Congenital aphakia (ICD-9 743.35)

One pair of eyeglasses or contact lenses after each cataract surgery.

For aphakic patients (ICD-9 379.31, 743.35), the following lenses or combinations of lenses are covered when determined to be medically necessary:

  1. Bifocal lenses in frames; or
  2. Lenses in frames for far vision and lenses in frames for near vision; or
  3. When a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), payment will be made for the contact lens(es), and lens(es) in frames for near vision to be worn at the same time as the contact lens(es), and lenses in frames to be worn when the contacts have been removed.

Lenses made of polycarbonate or other impact-resistant materials (V2784) only for patients with functional vision in only one eye.

Anti-reflective coating (V2750), tints (V2744, V2745), or oversize lenses (V2780) are covered only when they are medically necessary for the individual patient and the medical necessity is documented by the treating physician.

Noncoverage Indications

Frames provided without a covered lens(es) will be denied as noncovered.

Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered.

Use of polycarbonate or similar material (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature.

Specialty occupational multifocal lenses (V2786) will be denied as noncovered.

Additional charges for deluxe frames (V2025) will be denied as noncovered.

Hydrophilic soft contact lenses (V2520–V2523) that are used as a corneal dressing, are denied as noncovered because they do not meet the definition of a prosthetic device.

Eyeglass cases (V2756), contact lens cleaning solution, normal saline for contact lenses Low vision aids (V2600–V2615) will be denied as noncovered.

Vision supplies, accessories, and/or service components of another Healthcare Common Procedure Coding System (HCPCS) vision code (V2797) will be denied as not separately payable.

Coverage Limitations

Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are not covered when these features are provided as a patient preference.

UV coating (V2755) is not medically necessary for polycarbonate lenses (V2784) and if billed together, V2755 will be denied as not medically necessary.

Tinted lenses (V2745), including photo-chromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to an aphakic patient, will be denied as not medically necessary.

HCPCS Modifiers and Documentation

EY – No physician or other health care provider order for this item or service
KX  – Specific required documentation on file
LT – Left side
RT – Right side

Valid Order

  • A written order must be signed and dated by the treating physician prior to claim submission and kept on file by the supplier
  • The order must include the ICD-9 diagnosis code, and or a narrative diagnosis for the condition necessitating the lens(es).

The ICD-9 code that justifies the need for these items must be included on the claim.

If aphakia is the result of the removal of a previously implanted lens, the date of the surgical removal of the lens must accompany the claim.

The KX modifier must only be used when these requirements are met.

  • When the KX modifier is billed, documentation to support the medical necessity of the lens feature must be available to the DMERC on request.
  • For anti-reflective coating (V2750), tints (V2744, V2745), or oversized lenses (V2780), if they are specifically ordered by the treating physician and are not only a patient preference item.
  • For polycarbonate or Trivex™ lenses (V2784), if they are specifically ordered by the physician for a patient with monocular vision.

The EY modifier must be used when it is only a patient preference item and not ordered by the treating physician for anti-reflective coating (V2750), polycarbonate or Trivex™ lenses (V2784), tints (V2744, V2745), or oversized lenses (V2780).

Refractive Lenses
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