An eye prosthesis is covered for a patient with absence or shrinkage of an eye due to birth defect, trauma or surgical removal.  An eye prosthesis for any other condition will be denied as not medically necessary.

Polishing and resurfacing (V2624) is covered on a twice per year basis.

One enlargement (V2625) or reduction (V2626) of the prosthesis is covered.  Additional enlargements or reductions are rarely medically necessary and are therefore covered only when there is information in the medical record which supports medical necessity that must be available upon request.

If an item or service does not meet the criteria specified in this policy, it will be denied as not medically necessary unless there is documentation in the medical record clearly explaining the medical necessity in the individual situation.

Services that do not meet the medical necessity criteria documented in this policy will be considered not medically necessary. A participating, preferred, or network 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 should be maintained in the provider's records.

Replacement of an ocular prosthesis is governed in accordance with the Medicare five (5) year reasonable useful lifetime rule.  Replacement of a prosthesis or prosthetic component prior to five years is covered if the prosthesis is irreparably damaged, lost or stolen.

Replacement of an ocular prosthesis because of loss or irreparable damage may be reimbursed without a physician’s order when it is determined that the prosthesis as originally ordered still fills the patient’s medical needs.

Description

Ocular prosthesis, or artificial eyes, are prosthetic devices used to simulate a natural eye. An ocular prosthesis does not restore lost vision. The primary purpose of an ocular prosthesis is to maintain the volume of the eye socket, and to restore appearance to that of a natural eye.  Ocular prosthesis can be made to fit many different types of eye sockets and their associated conditions.

Documentation Requirements

An order for each item billed 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.

The physician’s records must contain information which supports the medical necessity of the item ordered.  The ocularist’s documentation of the necessity for replacement prosthesis is appropriate documentation for that claim if the replacement is necessitated by other than medical reasons.

When billing for an item or service at a greater frequency than that described in the policy, there must be documentation in the patient’s medical records that corroborates the order and supports the medical necessity of the items and quantities billed.

Coding Guidelines 

Trial scleral shells must be billed with code L9900.

Trial scleral cover shells are not separately payable.  They are included in the allowance for scleral cover shells, V2627.

The RT and LT modifiers must be used with all procedure codes in this policy. When ocular prostheses are provided bilaterally and the same code is used for both prostheses, bill both on the same claim line using the LTRT modifier and 2 units of service.

Coverage for prosthetics is determined according to individual or group customer benefits.

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.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

Vincent AL, Web MC, Gallie BL, etal.  Prosthetic conformers:  a step towards improved rehabilitation of enucleated children.  Clin Experiment Ophthalmol.  2002;30(1):58-59.

Custer PL, Kennedy RH, Woog JJ, et al.  Orbital implants in enucleation surgery:  a report by the American academy of ophthalmology.  Ophthalmology.  2003;110(10):2054-2061.

Chin K, Margolin CB, Finger PT.  Early ocular prosthesis insertion improves quality of life after enucleation.  Optometry.  2006;77(2):71-75.

Song JS, Oh J, Baek SH.  A survey of satisfaction in anophthalmic patients wearing ocular prosthesis.  Graefes Arch Clin Exp Ophthalmol.  2006;244(3):330-335.

Dolan L.  Orbital lymphoma presenting as an unstable ocular:  a salutary lesson.  Orbit. 01 Jan 2008; 27(4):317-9.

Patil SB. Ocular prosthesis:  a brief review and fabrication of an ocular prosthesis for a geriatric patient.  Gerodontology.  01 Mar 2008;25(1):57-62.