Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 02 |01 | 2023 POLICY LAST UPDATED: 02 | 01 | 2023

OVERVIEW Medicare Advantage Plans
This policy addresses coverage guidelines under the members Medicare Advantage Plans for eyeglasses or contact lenses following cataract surgery, for congenital aphakia or when used a bandage to promote healing in a diseased eye.

Commercial Plans Coverage for contact lenses and scleral bandages are limited to use as a bandage for the eye for the promotion of healing are covered. Eyewear and contact lenses for all other indications are not covered under the members medical plans.

Note: Benefits may vary as there are a limited number of commercial plans that have coverage for eyewear and contacts as part of the Pediatric Vision Care for members under age 19. Please refer to the members Coverage Booklet or Subscriber Agreement for Coverage details.

MEDICAL CRITERIA None

PRIOR AUTHORIZATION Prior authorization review is not required.

POLICY STATEMENT Medicare Advantage Plans Aphakia Eyewear and contact lenses for members who are aphakic (had a cataract removed but did not have an implanted intraocular lens (IOL) or who have the congenital absence of the lens the following services are considered medically necessary:  Bifocal lenses in frames; or  Lenses in frames for far vision and lenses in frames for near vision; or  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.

Replacement Lenses are covered when medically necessary

The following services are covered when medically necessary and prescribed by the treating physician
 Anti-reflective coating
 Tints
 oversize lenses
 UV protection

The following services are not medically necessary

Payment Policy | Therapeutic Eyeglasses and Contact Lenses

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

 UV coating on polycarbonate lenses
 Tinted lenses including photochromatic lenses when used as sunglasses prescribed in addition to regular glasses

Lenses made of polycarbonate or other impact materials are covered only for members who have functional vision in only one eye.

Pseudoaphakia For members who have had Pseudoaphakia (cataract removed and the insertion of an interocular lens IOL), coverage is limited to the following:

 One pair of standard frames or contact lenses
 bifocal or trifocal lenses  If 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, there is coverage for only one pair of eyeglasses or contact lenses after the second surgery.
 If 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).  Refer to coding section of this policy for specific features that are covered

Replacement frames, eyeglass lenses and contact lenses are not covered

Coverage Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage, for the applicable "Medical Vision" benefits/coverage.

If the policy criteria above are not met, the services may be covered under the member's stand-alone vision plan or vision rider; in the absence of a vision rider the member is responsible for payment

BACKGROUND Aphakia is the absence of the lens of the eye due to surgical removal (cataract surgery), perforating wound or ulcer, or congenital anomaly. In cataract surgery, the lens is removed as it has become cloudy. A small incision is made in the eye and the cataract is removed by breaking it up with ultrasound, a laser, or a water jet and taking out the pieces (phacoemulsification). When all the cataract pieces have been removed, the surgeon normally replaces the cataract with an artificial lens (intraocular lens). Intraocular lenses (IOL) are permanent, artificial lenses that are surgically implanted in the eye to replace or supplement the crystalline lens of the eye. Intraocular lenses are not considered to be contact lenses. In some instances, an intraocular lens cannot always be safely placed, and the individual must wear eyeglasses or contact lenses after the cataract has been removed.

Pseudophakia refers to an eye condition whereby; intraocular lens is implanted in the eyes to replace the natural lens. The natural lens is usually replaced as a result of being clouded over by a cataract

Monofocal lenses are the most commonly implanted intraocular lenses. They have equal power in all regions of the lens and can provide high-quality distance vision, usually with only a light pair of spectacles. Monofocal lenses are in sharpest focus at only one distance. They do not correct pre-existing astigmatism, a result of irregular corneal shape that can distort vision at all distances. Patients who have had monofocal intraocular lenses implanted usually require reading glasses.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Toric lenses have more power in one specific region in the lens to correct astigmatism as well as distance vision. Due to the difference in lens power in different areas, the correction of astigmatism with a toric lens requires that the lens be positioned in a very specific configuration. While toric lenses can improve distance vision and astigmatism, the patient still will require corrective lenses for all near tasks, such as reading or writing.

A presbyopia-correcting IOL implantation following the surgical removal of the lens or congenital aphakia is intended to provide correction for close-up and distance vision eliminating the need for eyeglasses or contact lenses.

Regular astigmatism is a visual condition where part of an image is blurred due to uneven corneal curvature. An astigmatism-correcting IOL is intended to provide what is otherwise achieved by eyeglasses or contact lenses. The astigmatism may be corrected at the time of cataract surgery by making one or two additional incisions in the periphery of the cornea. People with significant astigmatism require corrective lenses for sharpest vision at all distances.

The most common ocular surface disorders stem from tear-film abnormalities and lid-gland dysfunction (“blepharitis”), either of which may lead to ocular surface disorders. The use of terms such as dry eye (DE), ocular surface disease (OSD), or deficient tear syndrome (DTS), represents attempts to describe signs of clinical damage to the intrapalpebral ocular surface or symptoms of such disruption from a variety of causes.

Types of Lenses
Progressive Lenses Progressive lens 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.

Hydrophilic lenses Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, dry eyes, corneal ulcers and erosion, keratitis, corneal edema, descemetocele, corneal ectasis, Mooren’s ulcer, anterior corneal dystrophy, and for other therapeutic reasons. Hydrophilic contact lenses are not covered when used in the
treatment of nondiseased eyes with spherical ametrophia, refractive astigmatism and/or corneal astigmatism.2

Scleral lenses Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. A scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens which covers only the central non-white area encompassing the pupil and iris. Where an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant.

Scleral lenses may be used to improve vision and reduce pain and light sensitivity for people suffering from growing number of disorders or injuries to the eye. These include Microphthalmia, corneal ectasia, Stevens–Johnson syndrome, Sjögren's syndrome, aniridia, neurotrophic keratitis (anaesthetic corneas), complications post-LASIK, complications post-corneal transplant and pellucid degeneration. Injuries to the eye such as distorted corneal implants, as well as chemical and burn injuries may also be treated using scleral lenses.

Coding Medicare Advantage Plans
The following CPT code(s) are covered when filed with any of these diagnosis code(s): H27.00-H27.03 or Q12.3:

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

92311 Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, one eye. 92312 Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, both eyes. 92313 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, corneoscleral lens 92315 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, 1 eye 92316 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes 92317 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens 92352 Fitting of spectacle prosthesis for aphakia; monofocal

The following HCPCS code(s) are covered when a member has one of these codes filed in the previous 9 months: 66830 or 66987
Frames
V2020 Frames purchases V2025 Deluxe frame

Lenses
V2100 Sphere, single vision, plano to plus or minus 4. 00, per lens V2101 Sphere, single vision, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2102 Sphere, single vision, plus or minus 7. 12 to plus or minus 20. 00d, per lens V2103 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere,. 12 to 2.00d cylinder, per lens. V2104 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, 2. 12 to 4.00d cylinder, per lens V2105 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, 4. 25 to 6.00d cylinder, per lens V2106 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, over 6.00d cylinder, per lens V2107 Spherocylinder, single vision, plus or minus 4. 25 to plus or minus 7. 00 sphere, .12 to 2.00d cylinder per lens V2108 Spherocylinder, single vision, plus or minus 4. 25d to plus or minus 7. 00d sphere, .12 to 2.00d cylinder per lens V2109 Spherocylinder, single vision, plus or minus 4. 25 to plus or minus 7. 00d sphere, 4.25 to 6.00d cylinder V2110 Spherocylinder, single vision, plus or minus 4. 25 to 7. 00d sphere, over 6.00d cylinder per lens V2111 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d shere, .25 to 2.25d cylinder, per lens V2112 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d sphere, 2.25d to 4.00d cylinder V2113 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d sphere, 4.25 to 6.00d cylinder, per lens V2114 Spherocylinder, single vision, sphere over plus or minus 12. 00d, per lens V2115 Lenticular, (myodisc), per lens, single vision V2118 Aniseikonic lens, single vision

V2121 Lenticular lens, per lens, single V2199 Not otherwise classified, single vision lens V2200 Sphere, bifocal, plano to plus or minus 4. 00d, per lens V2201 Sphere, bifocal, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2202 Sphere, bifocal, plus or minus 7. 12 to plus or minus 20. 00d, per lens V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens V2214 Spherocylinder, bifocal, sphere over plus or minus 12. 00d, per lens V2215 Lenticular (myodisc), per lens, bifocal V2218 Aniseikonic, per lens, bifocal V2219 Bifocal seg width over 28mm V2220 Bifocal add over 3. 25d V2221 Lenticular lens, per lens, bifocal V2299 Specialty bifocal (by report) V2300 Sphere, trifocal, plano to plus or minus 4. 00d, per lens V2301 Sphere, trifocal, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2302 Sphere, trifocal, plus or minus 7. 12 to plus or minus 20. 00, per lens V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder, per lens V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens V2307 Spherocylinder, trifocal, plus or minus 4. 25 to plus or minus 7. 00d spher... V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder,

per lens V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder,
per lens V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens V2314 Spherocylinder, trifocal, sphere over plus or minus 12. 00d, per lens V2315 Lenticular, (myodisc), per lens, trifocal V2318 Aniseikonic lens, trifocal V2319 Trifocal seg width over 28 mm V2320 Trifocal add over 3. 25d V2321 Lenticular lens, per lens, trifocal V2399 Specialty trifocal (by report) V2410 Variable asphericity lens, single vision, full field, glass or plastic, per lens V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens V2499 Variable sphericity lens, other type

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

Contact Lenses
V2500 Contact lens, pmma, spherical, per lens V2501 Contact lens, pmma, toric or prism ballast, per lens V2502 Contact lens pmma, bifocal, per lens V2503 Contact lens, pmma, color vision deficiency, per lens V2510 Contact lens, gas permeable, spherical, per lens V2511 Contact lens, gas permeable, toric, prism ballast, per lens V2512 Contact lens, gas permeable, bifocal, per lens V2513 Contact lens, gas permeable, extended wear, per lens V2520 Contact lens, hydrophilic, spherical, per lens V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens V2522 Contact lens, hydrophillic, bifocal, per lens V2523 Contact lens, hydrophilic, extended wear, per lens V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens modification
V2531 Contact lens, scleral, gas permeable, per lens (for contact lens modification V2599 Contact lens, other type

Low vision aids
V2600 Hand held low vision aids and other nonspectacle mounted aids V2610 Single lens spectacle mounted low vision aids V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system

Miscellaneous V2700 Balance lens, per lens V2702 Deluxe lens feature V2710 Slab off prism, glass or plastic, per lens V2715 Prism, per lens V2718 Press-on lens, fresnell prism, per lens V2730 Special base curve, glass or plastic, per lens V2744 Tint, photochromatic, per lens V2745 Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens V2750 Anti-reflective coating, per lens V2755 U-v lens, per lens V2756 Eye glass case V2760 Scratch resistant coating, per lens V2761 Mirror coating, any type, solid, gradient or equal, any lens material, per lens.. V2762 Polarization, any lens material, per lens V2770 Occluder lens, per lens V2780 Oversize lens, per lens V2781 Progressive lens, per lens V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens V2784 Lens, polycarbonate or equal, any index, per lens

The following HCPCS code(s) are covered when a member has one of these codes filed in the previous 9 months: 66920. 66930, 66940, 66982, 66983, 66984 or 66988 Frames

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 7 (401) 274-4848 WWW.BCBSRI.COM

V2020 Frames, purchases

Lenses V2100 Sphere, single vision, plano to plus or minus 4. 00, per lens V2101 Sphere, single vision, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2102 Sphere, single vision, plus or minus 7. 12 to plus or minus 20. 00d, per lens V2103 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere,. 12 to 2.00d cylinder, per lens. V2104 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, 2. 12 to 4.00d cylinder, per lens V2105 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, 4. 25 to 6.00d cylinder, per lens V2106 Spherocylinder, single vision, plano to plus or minus 4. 00d sphere, over 6.00d cylinder, per lens V2107 Spherocylinder, single vision, plus or minus 4. 25 to plus or minus 7. 00 sphere, .12 to 2.00d cylinder per lens V2108 Spherocylinder, single vision, plus or minus 4. 25d to plus or minus 7. 00d sphere, .12 to 2.00d cylinder per lens V2109 Spherocylinder, single vision, plus or minus 4. 25 to plus or minus 7. 00d sphere, 4.25 to 6.00d cylinder V2110 Spherocylinder, single vision, plus or minus 4. 25 to 7. 00d sphere, over 6.00d cylinder per lens V2111 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d shere, .25 to 2.25d cylinder, per lens V2112 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d sphere, 2.25d to 4.00d cylinder V2113 Spherocylinder, single vision, plus or minus 7. 25 to plus or minus 12. 00d sphere, 4.25 to 6.00d cylinder, per lens V2114 Spherocylinder, single vision, sphere over plus or minus 12. 00d, per lens V2199 Not otherwise classified, single vision lens V2121 Lenticular lens, per lens, single V2200 Sphere, bifocal, plano to plus or minus 4. 00d, per lens V2201 Sphere, bifocal, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2202 Sphere, bifocal, plus or minus 7. 12 to plus or minus 20. 00d, per lens V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per l

lens V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per l

lens V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens V2214 Spherocylinder, bifocal, sphere over plus or minus 12. 00d, per lens V2215 Lenticular (myodisc), per lens, bifocal V2218 Aniseikonic, per lens, bifocal V2219 Bifocal seg width over 28mm V2220 Bifocal add over 3. 25d

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 8 (401) 274-4848 WWW.BCBSRI.COM

V2221 Lenticular lens, per lens, bifocal V2315 Lenticular, (myodisc), per lens, trifocal V2318 Aniseikonic lens, trifocal V2319 Trifocal seg width over 28 mm V2320 Trifocal add over 3. 25d V2321 Lenticular lens, per lens, trifocal V2299 Specialty bifocal (by report) V2300 Sphere, trifocal, plano to plus or minus 4. 00d, per lens V2301 Sphere, trifocal, plus or minus 4. 12 to plus or minus 7. 00d, per lens V2302 Sphere, trifocal, plus or minus 7. 12 to plus or minus 20. 00, per lens V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder, per lens V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens V2307 Spherocylinder, trifocal, plus or minus 4. 25 to plus or minus 7. 00d spher... V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens V2399 Specialty trifocal (by report) V2410 Variable asphericity lens, single vision, full field, glass or plastic, per lens V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens V2499 Variable sphericity lens, other type

Contacts V2500 Contact lens, pmma, spherical, per lens V2501 Contact lens, pmma, toric or prism ballast, per lens V2502 Contact lens pmma, bifocal, per lens V2503 Contact lens, pmma, color vision deficiency, per lens V2510 Contact lens, gas permeable, spherical, per lens V2511 Contact lens, gas permeable, toric, prism ballast, per lens V2512 Contact lens, gas permeable, bifocal, per lens V2513 Contact lens, gas permeable, extended wear, per lens V2520 Contact lens, hydrophilic, spherical, per lens V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens V2522 Contact lens, hydrophillic, bifocal, per lens V2523 Contact lens, hydrophilic, extended wear, per lens V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens modification V2531 Contact lens, scleral, gas permeable, per lens (for contact lens modification V2599 Contact lens, other type

Miscellaneous V2700 Balance lens, per lens V2710 Slab off prism, glass or plastic, per lens

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 9 (401) 274-4848 WWW.BCBSRI.COM

V2715 Prism, per lens V2718 Press-on lens, fresnell prism, per lens V2730 Special base curve, glass or plastic, per lens V2770 Occluder lens, per lens Medicare Advantage Plans and Commercial The following code(s) are covered when used as a corneal bandage: 92071 for fitting of contact lens to treat ocular surface disease V2520 Contact lens, hydrophilic, spherical, per lens V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens V2522 Contact lens, hydrophillic, bifocal, per lens V2523 Contact lens, hydrophilic, extended wear, per lens

The following HCPCS code(s) is covered but not separately reimbursed V2797 Vision supply, accessory and/or service component of another HCPCS vision code

Published Provider Update, April 2023 Provider Update, June 2021 Provider Update, April 2019 Provider Update, March 2018 Provider Update, February 2017 Provider Update, October 2015

Resources 1 American Optometric Association (AOA) Optometric Clinical Practice Guideline: Care Of The Patient With Ocular Surface Disorders. Accessed 01/31/2012 Http://Www.Aoa.Org/Documents/Cpg-10.Pdf 2 Centers for Medicare and Medicaid Services: Internet-Only Manual (IOMs). Medicare National Coverage Determinations Manual Chapter 1, Part 1 (Sections 80-80.12- Eye).
3 Centers for Medicare and Medicaid Services: National Coverage Determination (NCD) for Scleral Shell (80.5).
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx 4 Centers for Medicare and Medicaid Services: Internet-Only Manuals (IOMs). Medicare Benefit Policy Manual- Chapter 15 – Covered Medical and Other Health Services (Section 120-B-1, 2, and 3).
http://www.cms.gov/manuals/Downloads/bp102c15.pdf 5 Medscape Education Ophthalmology: Glaucoma Expert Column Series. Glaucoma and Ocular Surface Disease: An Expert Interview With Dr. Deepak Edward

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 10 (401) 274-4848 WWW.BCBSRI.COM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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