Medical Policy

Effective Date:11/01/2010 Title:Contact Lenses
Revision Date:10/01/2020 Document:BI066:00
CPT Code(s):92071, 92072, 92310-92317, 92325, 92326, S0500, S0512, S0514, V2500-V2503, V2510-V2513, V2520-V2523, V2524, V2530, V2599, V2630, V2786, V2787, V2788
Public Statement

Effective Date:

 

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Contact lenses are generally not covered, as they are for vision correction, and vision correction is not a covered service. Services for prescribing and fitting contact lenses are not covered.

 

When contact lenses are for treatment of disease other than vision disturbance, or for replacement of the lens of the eye, they may be covered.

Medical Statement
Limits

Refer to member contract booklet for any specific exclusions.

 

Replacement lenses for the above covered indications will be covered when there is a change in prescription that in the opinion of a Plan physician, necessitates obtaining new contacts.  Contacts prescribed as a prosthetic or bandage will also be replaced when the life expectancy of the product has expired.  Replacement shall not be covered for lost, damaged, misused, or abused contact lenses.

 

Contact lenses or glasses to correct vision in any circumstance not mentioned above are covered only if the member’s contract includes vision care and corrective lenses. 

 

V2599 is a nonspecific code and is not covered (specific codes should be used).

V2786-V2788 are not covered by Medicare or QualChoice.

Reference

Addendum:

1.     Effective 01/01/2017:  Removed CPT code 92070 from BI and replaced with codes 92071 and 92072, effective 1/1/2012. Also removed CPT code 92391, code deleted 1/1/2006.

2.     Effective 02/01/2018:  added scleral gas permeable contact lenses for diagnosis of keratoconus.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.