LCD/NCD Portal

L11519 EYE PROSTHESIS

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

• For any item to be covered by Medicare, it must

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o 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.

o 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.

o 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.

 

 

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

 

 

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.

o 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.

o 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.

o 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.

• This information must be available upon request.

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

 

 

Sources of Information and Basis for Decision

 

A33712 - Eye Prostheses - Policy Article - Effective July 2009

 

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