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.  
  
The purpose of a Local Coverage Determination (LCD) is to provide information
regarding "reasonable and necessary" criteria based on Social Security Act 
1862(a)(1)(A) provisions.  
  
In addition to the "reasonable and necessary" criteria contained in this LCD
there are other payment rules, which are discussed in the following documents,
that must also be met prior to Medicare reimbursement:

  * The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  * The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  * Refer to the Supplier Manual for additional information on documentation requirements.

  * Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the "reasonable and necessary" criteria,
based on Social Security Act  1862(a)(1)(A) provisions, are defined by the
following coverage indications, limitations and/or medical necessity.  
  
Statutory coverage criteria for refractive lenses are specified in the related
Policy Article.  
  
For beneficiaries 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), the following lenses or combinations of lenses are covered when
determined to be medically necessary:

  1. Bifocal lenses in frames; or
  2. Lenses in frames for far vision and lenses in frames for near vision; or
  3. 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 beneficiaries 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 beneficiaries (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 beneficiaries.  
  
Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses
(V2780) are covered only when they are medically necessary for the individual
beneficiary and the medical necessity is documented by the treating
practitioner. When these features are provided as a beneficiary preference
item and are billed with an EY modifier (see LCD-related Standard
Documentation Requirements Article), 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 practitioner 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. 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 related
Policy Article.  
  
Tinted lenses (V2745), including photochromatic lenses (V2744), used as
sunglasses, which are prescribed in addition to regular prosthetic lenses to
an aphakic beneficiary, will be denied as not reasonable and necessary.  
  
Lenses made of polycarbonate or other impact-resistant materials (V2784) are
covered only for beneficiaries with functional vision in only one eye. 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.  
  
GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a
claim is submitted. If the supplier bills for an item addressed in this policy
without first receiving a completed SWO, the claim shall be denied as not
reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
base items that require a Written Order Prior to Delivery (WOPD), the supplier
must have received a signed SWO before the DMEPOS item is delivered to a
beneficiary. If a supplier delivers a DMEPOS item without first receiving a
WOPD, the claim shall be denied as not reasonable and necessary. Refer to the
LCD-related Policy Article, located at the bottom of this policy under the
Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed
associated options, accessories, and/or supplies, the supplier must have
received a WOPD which lists the base item and which may list all the
associated options, accessories, and/or supplies that are separately billed
prior to the delivery of the items. In this scenario, if the supplier
separately bills for associated options, accessories, and/or supplies without
first receiving a completed and signed WOPD of the base item prior to
delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines
listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC
articles. Claims that do not meet coding guidelines shall be denied as not
reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are
required to maintain POD documentation in their files. Proof of delivery
documentation must be made available to the Medicare contractor upon request.
All services that do not have appropriate proof of delivery from the supplier
shall be denied as not reasonable and necessary.