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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/01/2010 Title: Contact Lenses
Revision Date: 02/01/2018 Document: BI066:00
CPT Code(s): 92071, 92072, 92310-92317, 92325, 92326, S0500, S0512, S0514 , V2500-V2503, V2510-V2513, V2520-V2523, V2530, V2599, V2630, 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

Standard Intraocular lenses (IOC) implants are covered as a basic medical service see BI 254.

 

Hydrophyllic (soft) contact lenses are covered as a prosthetic when they are prescribed for an aphakia (loss of natural lens) due to surgical removal (cataract extraction) or congenital absence, unless otherwise stated in the member’s contract.

 

Hydrophyllic (soft) contact lenses that are part of a treatment plan (used as a moist corneal bandage in the treatment of acute or chronic pathology) are covered as a supply incidental to physician services (see Supplies Policy).  Examples:  corneal ulcers, keratitis, bullous keratopathy, and other corneal diseases.

 

Scleral gas permeable   contact lenses (V2531) are covered for the diagnosis of Keratoconus.

 

Long term vision correction is covered for a post-cataract patient only if there was no intraocular lens implanted, and is limited to soft contact lenses as noted above.

 

The non-coverage status can be overridden by any Case Management Nurse using the benefit override process.

 

Codes Used In This BI:

 

92310           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens, both eyes, except for aphakia.

92313           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneoscleral lens

92314           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, direction of fitting by independent practitioner, corneal lens, both eyes, not for aphakia

92317           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, direction of fitting by independent practitioner, corneoscleral lens

92325           Modification of contact lens (separate procedure) with medical supervision of adaptation

92326           Replacement of contact lens

S0500           Disposable contact lenses, per lens

S0512           Daily wear specialty contact lens, per lens

S0514           Color contact lens, per lens

V2500           Contact lens, PMMA, spherical, per lens

V2501           Contact lens, PMMA, toric or prism ballast, per lens

V2502           Contact lens, PMMA, bifocal, per lens

V2503           Contact lens, PMMA, color vision deficiency, per lens

V2510           Contact lens, gas permeable, spherical, per lens

V2511           Contact lens, gas permeable, toric or prism ballast, per lens

V2512           Contact lens, gas permeable, bifocal, per lens

V2513           Contact lens, gas permeable, color vision deficiency, per lens

V2520           Contact lens hydrophilic

V2521           Contact lens, hydrophilic, toric or prism ballast, per lens

V2522           Contact lens, hydrophilic, bifocal, per lens

V2523           Contact lens, hydrophilic, color vision deficiency, per lens

V2530           Contact lens, scleral, gas impermeable, per lens

V2531           Contact lens, scleral, gas permeable, per lens

V2599           Contact lens, other type

V2630           Anter chamber intraocul lens

V2787           Astigmatism-correct function

V2788           Presbyopia-correct function

92071           Fitting of contact lens for treatment of ocular surface disease

92311           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens for aphakia, one eye

92312           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens for aphakia, both eyes

92315           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, direction of fitting by independent practitioner, corneal lens for aphakia, one eye

92316           Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, direction of fitting by independent practitioner, corneal lens, for aphakia, both eyes

92072           Fitting of contact lens for management of keratoconus, initial fitting


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. 


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.
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