AetnaCommercial Clinical Policy

Eye Prosthesis Form

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Eye Prosthesis Replacement

Indications

(915963) Is the need for an eye prosthesis due to absence or shrinkage of an eye resulting from trauma, surgical removal, or congenital defect? 

Eye Prosthesis Replacement Frequency

Indications

(915964) Has it been at least 5 years since the last replacement of the eye prosthesis, or is there documentation that supports the medical necessity for more frequent replacement? 

Effective Date

06/18/2002

Last Reviewed

09/11/2023

Original Document

  Reference



Background for this Policy

This policy is based upon Medicare DME MAC policy.

Eye Prostheses Generated by Computer-Aided Design and Rapid Manufacturing

Alam and colleagues (2017) stated that ocular prosthesis is either a ready-made stock shell or custom made prosthesis (CMP). Presently, there is no other technology available, which is either superior or even comparable to the conventional CMP. In a pilot study, these researchers designed to fabricate ocular prosthesis using computer-aided design (CAD) and rapid manufacturing (RM) technology and compared it with CMP. The ocular prosthesis prepared by CAD was compared with conventional CMP in terms of time taken for fabrication, weight, cosmesis, comfort, and motility; 2 eyes of 2 patients were included. Computerized tomography scan of wax model of socket was converted into 3-D format using the Materialize Interactive Medical Image Control System (MIMICS) software and further refined. This was given as an input to rapid manufacturing machine (Polyjet 3-D printer). The final painting on prototype was done by an ocularist. The average effective time needed for fabrication of CAD prosthesis was 2.5 hours; and weighed 2.9 g. The same for CMP were 10 hours; and 4.4 g; CAD prosthesis was more comfortable for both the patients. The authors concluded that the findings of this study demonstrated the first ever attempt of fabricating a complete ocular prosthesis using CAD and rapid manufacturing and comparing it with conventional CMP. They reported that this prosthesis took lesser time for fabrication, and was more comfortable. They stated that studies with larger sample size are needed to further validate this technique.

Scope of Policy

This Clinical Policy Bulletin addresses eye prosthesis.

Medical Necessity

  • Aetna considers eye prostheses medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect.
  • Aetna considers twice-yearly polishing and re-surfacing of eye prosthesis medically necessary.
  • Aetna considers replacement of an eye prosthesis medically necessary every 5 years unless documentation supports the medical necessity of more frequent replacement.
  • Aetna considers one enlargement or reduction of the prosthesis medically necessary. Additional enlargements or reductions are rarely medically necessary.

    • Policy Limitations and Exclusions

    Note:

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