L11519-LCD

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Local Coverage Determination (LCD) for Eye Prosthesis (L11519)

Contractor Information

Contractor Name

CGS Administrators, LLC opens in new window

Contractor Number

18003

Contractor Type

DME MAC

Jurisdiction

J - G

LCD Information

Document Information

LCD ID Number L11519

LCD Title

Eye Prosthesis

Contractor's Determination Number EYE

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico

South Carolina Tennessee Texas

Virginia

Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993 Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy None

Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare 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 Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, 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.

An eye prosthesis is covered for a patient with absence or shrinkage of an eye due to birth defect, trauma or surgical removal.

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

One enlargement (V2625) or reduction (V2626) of the prosthesis is covered without documentation. 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. This information must be available upon request.

If an item or service does not meet the criteria specified in this section, 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.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage. HCPCS MODIFIERS:

EY - No physician or other licensed health care provider order for this item or service. LT - Left side

RT - Right side

HCPCS CODES:

L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE

V2623 PROSTHETIC EYE, PLASTIC, CUSTOM

V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS

V2625 ENLARGEMENT OF OCULAR PROSTHESIS V2626 REDUCTION OF OCULAR PROSTHESIS V2627 SCLERAL COVER SHELL

V2628 FABRICATION AND FITTING OF OCULAR CONFORMER V2629 PROSTHETIC EYE, OTHER TYPE

ICD-9 Codes that Support Medical Necessity Not specified.

XX000 Not Applicable

Diagnoses that Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity Not specified.

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

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 HCPCS 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 a 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. This information must be available upon request.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision Advisory Committee Meeting Notes

Start Date of Comment Period 04/30/1993

End Date of Comment Period 06/14/1993

Start Date of Notice Period 08/01/1993

Revision History Number 005

Revision History Explanation Revision Effective Date: 03/01/2008

In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 07/01/2007

INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: References to DMERC DOCUMENTATION REQUIREMENTS:

Removed: References to DMERC

Revision Effective Date: 06/01/2007

In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 03/01/2006

In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 07/01/2005 LMRP converted to LCD and Policy Article HCPCS CODES AND MODIFIERS:

Added: L9900

Revision Effective Date: 04/01/2003

HCPCS CODES AND MODIFIERS:

Added: EY, RT and LT

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added standard language concerning coverage of items without an order.

Revised coverage and payment of polishing and resurfacing services from once to twice per year. COVERED ICD-9 CODES:

No Changes

CODING GUIDELINES:

Added requirement to use the RT and LT modifiers. DOCUMENTATION REQUIREMENTS:

Added standard language concerning use of the EY modifier for items without an order.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)