Highmark Medicare Advantage Medical Policy in West Virginia

Section:	Miscellaneous
Number:	Z-50
Topic:	Determination of Refractive State
Effective Date:	January 1, 2010
Issued Date:	March 15, 2010
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Determination of refractive state (92015) performed for the following conditions is non-covered. A participating, preferred, or network provider can bill the member for the denied service.

routine eye examination
hypermetropia
myopia
astigmatism
anisometropia and aniseikonia
presbyopia
transient refractive change
unspecified disorder of refraction and accommodation
aphakia

There may be instances when the patient's visual acuity is impacted by a medical condition that can affect the ocular system (e.g., diabetes, macular degeneration, glaucoma, systemic diseases that affect neurological, vascular, endocrine or immune body systems, etc. This is not an all-inclusive list). In these cases, a refraction may be performed as part of the evaluation and monitoring of that condition. When the purpose of the refraction is to assess or monitor progression of a medical condition, rather than to evaluate the patient's degree of refractive error for the prescription of corrective lenses, it is a covered service. However, if the purpose of the refraction is solely to evaluate the degree of refractive error for the prescription of corrective lenses, the services are not covered. A participating, preferred, or network provider can bill the member for the denied service.

Refraction performed for evaluating medical conditions will typically be reported in conjunction with ophthalmological exam codes 92002-92014.

Refractions rendered at unusually frequent intervals may be reviewed for medical necessity of the services.

Additionally, refraction performed following ocular surgery is considered to be part of the doctor's normal postoperative care. Therefore, payment for the surgical procedure includes payment for refraction performed during the postoperative period for a definitive surgical procedure.

Description

Refraction is defined as determination of the nature and degree of the refractive errors of the eye and correction of the same by lenses. This may be done with or without eye drops in the eye. Refraction is performed by interposing lenses of different kinds in front of the eye until visual acuity is maximized. This examination provides the degree to which the eye differs from normal, which determines whether or not the patient needs corrective lenses and, if so, how strong they should be. Refraction is most commonly performed for purposes of prescribing corrective lenses. As such, it is not a benefit under most medical-surgical contracts.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

92015

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:

To correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery.
In lieu of surgery when the condition can be corrected by surgery, but surgery is precluded because of age or medical condition.

NOTE: Benefits are provided for refractions only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described above.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Procedure Code Attachments

Diagnosis Codes

Non-covered diagnosis codes (applicable to code 92015)

367.0	367.1	367.20-367.22	367.31-367.32
367.4	367.81	367.9	379.31
V72.0

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.