LCD/NCD Portal

L11522 REFRACTIVE LENSES

 

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 local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, 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 reasonable and necessary.

• Statutory coverage criteria for refractive lenses are specified in the related Policy Article.

• For patients who are aphakic (i.e., who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens) (ICD-9 379.31, 743.35), the following lenses or combinations of lenses are covered when determined to be medically necessary:

o Bifocal lenses in frames

o Lenses in frames for far vision and lenses in frames for near vision

o 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.

• For patients who are pseudophakic (i.e., those who have an IOL), refer to the Policy Article for information about coverage of the initial pair of lenses.

• For aphakic patients (i.e., those who do not have an IOL), replacement lenses are covered when they are medically necessary. Refer to the Policy Article for information about noncoverage of replacement lenses for pseudophakic patients.

• Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual patient and the medical necessity is documented by the treating physician.

o When these features are provided as a patient preference item and are billed with an EY modifier (see Documentation section), they will be denied as not reasonable and necessary.

• UV protection is considered reasonable and necessary following cataract extraction; therefore, additional medical necessity justification by the treating physician beyond inclusion on the order is not necessary.

• The addition of UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary.

o Additional information regarding the coding and billing of UV coating (V2755) on lenses with UV protective properties inherent in the material may be found in the Policy Article.

• Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to an aphakic patient, will be denied as not reasonable and necessary.

• Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for patients with functional vision in only one eye.

o In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are covered. Claims for code V2784 that do not meet this coverage criterion will be denied as not reasonable and necessary.

 

 

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

 

GA – Waiver of liability statement issued as required by payer policy, individual case

 

GZ – Item or service expected to be denied as not reasonable and necessary

 

KX - Requirements specified in the medical policy have been met

 

LT - Left side

 

RT - Right side

 

HCPCS CODES:

 

FRAMES:

 

V2020 FRAMES, PURCHASES

V2025 DELUXE FRAME

 

 

EYEGLASS 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, 2.12 TO 4.00D 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, PER LENS

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 SPHERE, .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, PER LENS

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, .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,.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, .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, .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 SPHERE, .12 TO 2.00D CYLINDER, PER LENS

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, .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

 

 

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, SEE 92325)

V2531 CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)

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

V2786 SPECIALTY OCCUPATIONAL MULTIFOCAL LENS, PER LENS

V2797 VISION SUPPLY, ACCESSORY AND/OR SERVICE COMPONENT OF ANOTHER HCPCS VISION CODE

V2799 VISION SERVICE, MISCELLANEOUS

 

 

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."

o 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.

o This documentation must be available upon request.

• An order for the lens (es) and related features 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.

• If the ordering physician is also the supplier, the prescription is an integral part of the patient's record.

• The ICD-9 code that justifies the need for these items must be included on the claim.

• KX, GA, and GZ MODIFIERS:

• For anti-reflective coating (V2750), tints (V2744, V2745) or oversized lenses (V2780), if medical necessity is documented by the treating physician, the KX modifier must be added to the code.

o For polycarbonate or Trivex TM lenses (V2784), if they are for a patient with monocular vision, the KX modifier must be added to the code.

o The KX modifier may only be used when these requirements are met.

o When the KX modifier is billed, documentation to support the medical necessity of the lens feature must be available upon request.

• For anti-reflective coating (V2750), polycarbonate or Trivex TM lenses (V2784), tints (V2744, V2745) or oversized lenses (V2780), if the coverage criteria have not been met, the GA or GZ modifier must be added to the code.

o When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

• Claims lines for anti-reflective coating (V2750), tints (V2744, V2745), oversized lenses (V2780) or polycarbonate or Trivex TM lenses (V2784) billed without a KX, GA, or GZ modifier will be rejected as missing information.

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

 

 

Sources of Information and Basis for Decision

 

A23975 - Refractive Lenses - Policy Article - Effective January 2011

 

 

Local Coverage Determination (LCD) for Refractive Lenses (L11522)