Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-4
Topic: Intraocular Lens (Pseudophakos)
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 08/2005

General Policy Guidelines

Indications and Limitations of Coverage

The intraocular lenses listed below are eligible prosthetic devices and are processed under the applicable procedure codes if a program benefit.

  1. Iris fixation lenses (V2631)
  2. Irido-capsular fixation lenses (L8499)
  3. Posterior chamber lenses (V2632)
  4. Anterior chamber angle fixation lenses (V2630)

Surgical fees for cataract extraction with lens insertion are to be paid under code 66982-66984, whichever is reported.

No payment should be made for the lens or any services furnished in connection with the implantation of a lens other than those listed above.

Prosthetic devices which are dispensed to a patient prior to performance of the procedure that will necessitate 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.

Description

An intraocular lens (pseudophakos) is a hard type of artificial lens which is surgically implanted in the eye to replace the natural crystalline lens.

Procedure Codes

6698266983669846698566986L8499
V2630V2631V2632   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

MCM 5256
MCIM 65-7

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Table Attachment

Text Attachment

Procedure Code Attachment


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 Mountain State Blue Cross Blue Shield 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.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.