Refractive error is an optical defect that occurs when light rays entering the eye are not brought to sharp focus on the retina, producing a blurred image. This can be corrected by eyeglasses, contact lenses or refractive surgery. Specific forms of refractive error include presbyopia, myopia (nearsightedness), hyperopia (farsightedness) and astigmatism.

For any item to be covered, it must 1) be eligible for a defined benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable requirements.  For the items addressed in this medical policy, the criteria for "reasonable and necssary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered, a written signed and dated order must be received by the supplier before a claim is submitted.  If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual patient and the medical necessity is documented by the treating physician.  When these features are provided as a patient preference item and are billed with an EY modifier, they will be denied as not medically necessary. 

UV protection is considered reasonable and necessary following cataract extraction; therefore, additional medical necessity justification by the treating physician beyond inclusion on the order is not necessary.

For patients who are aphakic (i.e., who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens), the following lenses or combinations of lenses are covered when determined to be medically necessary:

1. Bifocal lenses in frames; or
2. Lenses in frames for far vision and lenses in frames for near vision; or
3. When a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), payment will be made for the contact lens(es), and lens(es) in frames for near vision to be worn at the same time as the contact lens(es) and lenses in frames to be worn when the contacts have been removed.

For aphakic patients (i.e, those who do not have an IOL), replacement lenses are covered when they are medically necessary.

Refractive lenses are covered even though the surgical removal of the natural lens occurred before Medicare entitlement.

Refractive lenses are covered when they are used to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence.  Covered diagnoses are limited to pseudophakia (condition in which the natural lens has been replaced with an artifical inraocular lens [IOC]), aphakia (condition in which the natural lens has been removed but there is no IOC) and congenital aphakia.  Lenses provided for other diagnoses will be denied as noncovered. The provider can bill the member for the denied service.

Lenses made of polycarbonate or other impact-resistant material (V2784) are covered only for patients with functional vision in only one eye.  In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are covered.  Claims for code V2784 that do not meet this coverage criterion will be denied as not medically necessary. 

Reasons for Noncoverage

The addition of UV coating (V2755) is not medically necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not medically necessary. 

Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to prosthetic lenses to an aphakia patient, will be denied as not medically necessary.

Because coverage of refractive lenses is based upon the Prosthetic Device benefit category, there is no coverage for frames or lens add-on codes unless there is a covered lens(es).  Frames provided without a covered lens(es) will be denied as noncovered.  The provider can bill the member for the denied service.

For patients with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL.  Replacement frames, eyeglass lenses and contact lenses are noncovered.  If a member has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, only one pair of eyeglasses or contact lenses after the second surgery will be covered. If a member has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye).

The provider can bill the member for the following noncovered services.

Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered.

Use of polycarbonate or similar material (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature.

Specialty occupational multifocal lenses (V2786) will be denied as noncovered.

Only standard frames (V2020) are covered.  Additional charges for deluxe frames (V2025) will be denied as noncovered.

When hydrophilic soft contact lenses (V2520-V2523) are used as a corneal dressing, they are denied as noncovered because in this situation they do not meet the definition of a prosthetic device.

Eyeglass cases (V2756) will be denied as noncovered.

Contact lens cleaning solution and normal saline for contact lenses will be denied as noncovered.

Low vision aids (V2600-V2615) will be denied as noncovered because coverage under the Prosthetic Benefit is limited to persons with congenital absence or surgical removal of the lens of the eye.

Vision supplies, accessories, and/or service components of another procedure vision code (V2797) will be denied as not separately payable.

Services that do not meet the medical necessity criteria will be considered not medically necessary.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

An order for the lens(es) and related features must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.  Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.

If the ordering physician is also the supplier, the prescription is an integral part of the member’s record.

The diagnosis code that justifies the need for these items must be included on the claim.

KX, GA and GZ Modifiers

For anti-reflective coating (V2750), tints (V2744, V2745) or oversized lenses (V2780), if medical necessity is documented by the treating physician, the KX modifier must be added to the code.  For polycarbonate or Trivex lenses (V2784), if they are for a patient with monocular vision, the KX modifier must be added to the code.  The KX modifier must only be used when these requirements are met.  When the KX modifier is billed, documentation to support the medical necessity of the lens feature must be available upon request.

For anti-reflective coating (V2750), polycarbonate or Trivex TM lenses (V2784), tints V2744, V2745) or oversized lenses (V2780), if the coverage criteria have not been met, the GA or GZ modifier must be added to the code.  When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Preservice Denial Notice or the GZ modifier if they have not obtained a valid Preservice Denial Notice.  The provider can bill the member if a GA modifier is entered on the claim.  A provider cannot bill the member if a GZ modifier is entered on the claim.

Claims lines for anti-reflective coating (V2750), tints (V2744, V2745), oversized lenses (V2780 or polycarbonate or Trivex TM lenses (V2784) billed without a KX, GA, or GZ modifier will be rejected as missing information.

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.

Deluxe lens features (V2702) include services and features such as lens edge treatments and lens drilling.

Photochromatic lenses (V2744) are those in which the degree of tint changes in response to changes in ambient light.  Code V2744 is used for any type of photochromatic lens, either glass or plastic.

Code V2745 is used for any type or color of lens tint, excluding photochromatic lenses.

Code V2755 must be used only if a UV coating is applied to a lens and not as an add-on code for the UV protection inherent in the lens material.

Anti-reflective coating (V2750) is a clear lens treatment used to decrease glare and internal/external reflections.

Mirror coatings (V2761) are colored, highly reflective lens treatments.

Progressive lens (V2781) is a multifocal lens that gradually changes in lens power from the top to the bottom of the lens, eliminating the line(s) that would otherwise be seen in a bifocal or trifocal lens.

Code V2784 is an add-on used for lenses made of impact-resistant material such as polycarbonate or Trivex.  Codes V2782 and V2783 (high index) must not be billed in addition to code V2784.

Codes V2100-V2114, V2199-V2214, V2299-V2314, V2399-V2499, V2700 and V2770 describe specific eyeglass lenses.  Only one of these codes may be billed for each lens provided.  These codes include both asperic and nonaspheric lenses.

Codes V2115, V2118, V2121, V2215, V2218-V2221, V2315, V2318-V2321, V2710-V2760 and V2780-V2797 describe add-on features of lenses.  They are billed in addition to codes for the basic lens.

When billing claims for deluxe frames, use code V2020 for the cost of standard frames and a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames.

When billing claims for progressive lens, use the appropriate code for the standard bifocal (V2200-V2299) or trifocal (V2300-V2399) lens and a second line item using code V2781 for the difference between the charge for the progressive lens and the standard lens.

The RT and LT modifiers must be used with all procedure codes in this policy except codes V2020, V2025 and V2600.  When lenses are provided bilaterally and the same code is used for both lenses, bill both on the same claim line using the LTRT modifier and two units of service.  Claims billed without modifiers RT and/or LT will be rejected as incorrect coding.