Medicare Advantage Medical Policy Bulletin
Section: CMS National Guidelines
Number: N-80
Topic: Hydrophilic Soft Contact Lenses, NCD 80.1 and 80.4
Effective Date: July 21, 2008
Issued Date: July 21, 2008

General Policy

Hydrophilic lenses are soft contact lenses which can be used:

  1. As prosthetic lenses for the aphakic patient.
  2. To improve visual acuity.
  3. As a corneal bandage (dressing) to hold medication in contact with the cornea or to protect the cornea from irritation.

Indications and Limitations of Coverage

Hydrophilic lenses are eligible for payment as prosthetic lenses (V2520-V2523, 92326) when the diagnosis is surgical or congenital aphakia (absence of the crystalline lens). Prosthetic lenses for conditions other than aphakia should be denied. They are not covered when used in the treatment of nondiseased eyes with spherical ametrophia, refractive astigmatism, and/or corneal astigmatism. A network provider can bill the member for the denied service.

Payment for hydrophilic lenses used as a corneal bandage is bundled into the payment for the physician’s service to which the lens is incident.  Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, such as bullous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, corneal edema, descemetocele, corneal ectasis, Mooren's ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis and for other therapeutic reasons. Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day.  When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

Semi-soft cataract lenses are subject to the same payment guidelines and reasonable charges as standard hydrophilic soft cataract lenses.

Lenses used to improve visual acuity are not covered. 

Prosthetic devices which are dispensed to a patient prior to performance of the procedure that will necessitate the use of the device are not covered. Dispensing a prosthetic device in this manner would not be considered reasonable and necessary for the treatment of the patient's condition.

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

92326V2520V2521V2522V2523V2599

Coding Guidelines

References

CMS On-Line Manual 100-02, Chapter 15, Section 120

CMS On-Line Manual 100-3, Sections 80.1 and 80.4

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

379.31743.35  

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.