Coverage Policies

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Current policies effective through April 30, 2024.

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INDEX:



Effective Date: 11/01/2010	Title: Contact Lenses
Revision Date: 06/01/2023	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
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. 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 V2524 Contact lens, hydrophilic, spherical, photochromic additive, 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. V2599 is a nonspecific code and is not covered (specific codes should be used). V2786-V2788 are not covered by Medicare or QualChoice.
Background
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 V2524 Contact lens, hydrophilic, spherical, photochromic additive, 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
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. 3. Effective 01/01/2020: Clarification of non-covered codes. 4. Effective 10/1/2020: New code V2524 added (non-covered). 5. Effective 06/01/2023: Removed limitation to soft contact lenses for long-term vision correction for post-cataract patients.
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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