Refractive Lenses - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
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. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").  
  
Refractive lenses are covered under the prosthetic devices benefit category
(Social Security Act 1861(s)(8)). In order for a beneficiary's equipment to
be eligible for reimbursement, the reasonable and necessary (R&N) requirements
set out in the related Local Coverage Determination must be met. In addition,
there are specific statutory payment policy requirements, discussed below,
that also must be met.  
  
Refractive lenses are covered when they are used to restore the vision
normally provided by the natural lens of the eye of an individual lacking the
organic lens because of surgical removal or congenital absence. Covered
diagnoses are limited to pseudophakia (condition in which the natural lens has
been replaced with an artificial intraocular lens [IOL]), aphakia (condition
in which the natural lens has been removed but there is no IOL), and
congenital aphakia. Lenses provided for other diagnoses will be denied as
noncovered.  
  
Refractive lenses are covered even though the surgical removal of the natural
lens occurred before Medicare entitlement.  
  
For beneficiaries with pseudophakia, coverage is limited to one pair of
eyeglasses or contact lenses after each cataract surgery with insertion of an
IOL. Replacement frames, eyeglass lenses and contact lenses are noncovered. If
a beneficiary 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, Medicare covers only one pair of eyeglasses or contact lenses
after the second surgery. If a beneficiary 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 the Local Coverage Determination (LCD) for information about coverage
of lenses for aphakic beneficiaries (i.e., those who do not have an IOL).  
  
Because coverage of refractive lenses is based upon the Prosthetic Device
benefit category, there is no coverage for frames or lens add-on codes unless
there is a covered lens(es). Frames provided without a covered lens(es) will
be denied as noncovered.  
  
Tinted lenses (V2745), including photochromatic lenses (V2744), used as
sunglasses, which are prescribed in addition to regular prosthetic lenses to a
pseudophakic beneficiary, will be denied as noncovered.  
  
Scratch resistant coating (V2760), mirror coating (V2761), polarization
(V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be
denied as noncovered.  
  
Use of polycarbonate or similar material (V2784) or high index glass or
plastic (V2782, V2783) for indications such as light weight or thinness will
be denied as a noncovered deluxe feature.  
  
Specialty occupational multifocal lenses (V2786) will be denied as noncovered.  
  
Only standard frames (V2020) are covered. Additional charges for deluxe frames
(V2025) will be denied as noncovered.  
  
When hydrophilic soft contact lenses (V2520, V2521, V2522, V2523) are used as
a corneal dressing, they are denied as noncovered because in this situation
they do not meet the definition of a prosthetic device.  
  
Eyeglass cases (V2756) will be denied as noncovered.  
  
Contact lens cleaning solution and normal saline for contact lenses will be
denied as noncovered.  
  
Low vision aids (V2600, V2610, V2615) will be denied as noncovered because
coverage under the Medicare prosthetic benefit is limited to persons with
congenital absence or surgical removal of the lens of the eye.  
  
Vision supplies, accessories, and/or service components of another HCPCS
vision code (V2797) will be denied as not separately payable.

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)**  
  
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).  
  
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.  
  
If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD, it will be eligible
for coverage.  
  
 **POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**  
  
In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.  
  
Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.  
  
The diagnosis code that justifies the need for these items must be included on
the claim.  
  
 **CONTINUED MEDICAL NEED**  
  
For all DMEPOS items, the initial justification for medical need is
established at the time the item(s) is first ordered, therefore, beneficiary
medical records demonstrating that the item is reasonable and necessary are
created just prior to, or at the time of, the creation of the initial
prescription. Once initial medical need is established, unless continued
coverage requirements are specified in the LCD, ongoing need for the lens(es)
is assumed to be met. There is no requirement for further documentation of
continued medical need as long as the beneficiary continues to meet the
prosthetic devices benefit.  
  
**MODIFIERS**  
  
KX, GA, GY and GZ MODIFIERS:  
  
For anti-reflective coating (V2750), tints (V2744, V2745) or oversized lenses
(V2780), if medical necessity is documented by the treating practitioner, the
KX modifier must be added to the code. For polycarbonate or Trivex TM lenses
(V2784), if they are for a beneficiary with monocular vision, the KX modifier
must be added to the code. The KX modifier may only be used when these
requirements are met. 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.
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.  
  
Claim lines for anti-reflective coating (V2750), tints (V2744, V2745),
oversized lenses (V2780) or polycarbonate or Trivex TM lenses (V2784) billed
without a KX, GA, GY or GZ modifier will be rejected as missing information.  
  
Refer to the Supplier Manual for more information on documentation
requirements.  
  

**CODING GUIDELINES**  
  
Deluxe lens features (V2702) include services and features such as lens edge
treatments and lens drilling.  
  
Photochromatic lenses (V2744) and contacts (V2524) are those in which the
degree of tint changes in response to changes in ambient light. Code V2744 is
used for any type of photochromatic lens, either glass or plastic. Code V2524
is used for any type of photochromatic contact lens.  
  
Code V2745 is used for any type or color of lens tint, excluding
photochromatic lenses.  
  
Code V2755 must be used only if a UV coating is applied to a lens and not as
an add-on code for the UV protection inherent in the lens material.  
  
Anti-reflective coating (V2750) is a clear lens treatment used to decrease
glare and internal/external reflections.  
  
Mirror coatings (V2761) are colored, highly reflective lens treatments.  
  
Progressive lens (V2781) 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.  
  
Code V2784 is an add-on used for lenses made of impact-resistant material such
as polycarbonate or Trivex TM. Codes V2782 and V2783 (high index) must not be
billed in addition to code V2784.  
  
Codes V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109,
V2110, V2111, V2112, V2113, V2114, V2199, V2200, V2201, V2202, V2203, V2204,
V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2299,
V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310,
V2311, V2312, V2313, V2314, V2399, V2410, V2430, V2499, V2700, and V2770
describe specific eyeglass lenses. Only one of these codes may be billed for
each lens provided. These codes include both aspheric and nonaspheric lenses.  
  
Codes V2115, V2118, V2121, V2215, V2218, V2219, V2220, V2221, V2315, V2318,
V2319, V2320, V2321, V2710, V2715, V2718, V2730, V2744, V2745, V2750, V2755,
V2756, V2760, and V2780, V2781, V2782, V2783, V2784, V2786, V2797 describe
add-on features of lenses. They are billed in addition to codes for the basic
lens.  
  
When billing claims for deluxe frames, use code V2020 for the cost of standard
frames and a second line item using code V2025 for the difference between the
charges for the deluxe frames and the standard frames.  
  
When billing claims for progressive lenses, use the appropriate code for the
standard bifocal (V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207,
V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220,
V2221, V2299) or trifocal (V2300, V2301, V2302, V2303, V2304, V2305, V2306,
V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319,
V2320, V2321, V2399) lenses and a second line item using code V2781 for the
difference between the charge for the progressive lens and the standard lens.  
  
The RT and/or LT modifiers must be used with all HCPCS codes in this policy
except codes V2020, V2025 and V2600. Effective for claims with dates of
service (DOS) on or after 3/1/2019, when lenses are provided bilaterally and
the same code is used for both lenses, bill each item on two separate claim
lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim
line. Do not use the RTLT modifier on the same claim line and billed with 2
UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same
claim line and 2 UOS, will be rejected as incorrect coding.

PROSE Device

PROSE (BostonSight, Needham, MA) devices are designed to rest on the sclera
or white part of the eye and are used to treat ocular surface diseases,
including some types of "dry eye." For Medicare billing purposes correct HCPCS
coding for this item is determined based upon the condition(s) being treated.
When the PROSE device is used as a treatment for either of the following
indications listed below, the correct HCPCS code to use is V2627 (SCLERAL
COVER SHELL):

  * Treatment of an eye rendered sightless and shrunken by inflammatory disease; or,

  * Treatment of "dry eye" where the PROSE device serves as a substitute for the function of the diseased lacrimal gland.

When the PROSE device is used for any conditions other than those listed
above, the device must be coded with HCPCS code V2531 (CONTACT LENS, SCLERAL,
GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)) and is
subject to the Medicare refractive lens statutory coverage exclusion.

Suppliers should contact the Pricing, Data Analysis and Coding
(PDAC)Contractor for guidance on the correct coding of these items.