New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 5 - VISION APPLIANCES, HEARING APPLIANCES, DURABLE MEDICAL EQUIPMENT, OXYGEN, MEDICAL SUPPLIES, PROSTHETICS AND ORTHOTICS › Section 8.324.5.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Vision appliances:
MAD covers specific vision care services that
				are medically necessary for the diagnosis of and treatment of eye diseases. MAD
				pays a provider for the correction of refractive errors that are required by
				the condition of the MAP eligible recipient. All services must be furnished
				within the limits of MAD benefits, within the scope and practice of the medical
				professional as defined by state law and in accordance with applicable federal,
				state and local laws and his or her New Mexico regulation and licensing
				division's (RLD) practice board.
(1) Exam:
				MAD covers routine eye exams. Coverage for a MAP eligible recipient over 22
				years of age is limited to one routine eye exam in a 36-month period. Exam
				coverage for a MAP eligible recipient under 21 years of age is limited to one
				routine eye exam in a 12-month period. If a MAP eligible recipient has
				transitioned from the early, periodic screening, diagnosis and treatment
				(EPSDT) program at age 21, the date of service for his or her last exam starts
				the 36-month period. An exam for an existing medical condition, such as
				cataracts, diabetes, hypertension, and glaucoma will be covered for required
				follow-up and treatment. The medical condition must be clearly documented on
				his or her visual examination record and indicated by diagnosis on the claim
				form.
(2) Corrective lenses: MAD
				covers one set of corrective lenses for a MAP eligible recipient 21 years of
				age and older not more frequently than once in a 36-month period. For a MAP
				eligible recipient under 21 years of age, one set of corrective lenses is
				covered no more frequently than once every 12 months. If a MAP eligible
				recipient has transitioned from the EPSDT program at age 21, the date of
				service for his or her last corrective lenses starts the 36-month period. For
				either age group, MAD covers corrective lenses more frequently when an
				ophthalmologist or optometrist recommends a change in prescription due to a
				medical condition, including but not limited to cataracts, diabetes,
				hypertension, glaucoma or treatment with certain systemic medications affecting
				vision. The vision prescription must be appropriately recorded on the MAP
				eligible recipient's visual examination record and indicated by a diagnosis on
				the claim.
(a) For the purchase of
				eyeglasses, the diopter correction must meet or exceed one of the following
				diopter correction criteria:
(i) -1.00 myopia
				(nearsightedness);
(ii) + 1.00 for
				hyperopia (farsightedness);
(iii)
				0.75 astigmatism (distorted vision), the combined refractive error of sphere
				and cylinder to equal 0.75 will be accepted;
(iv)
												±1.00 for presbyopia
				(farsightedness of aging); or
(v)
				diplopia (double vision) - prism lenses.
(b) When a MAP eligible recipient's existing
				prescription is updated and the frequency of replacement lenses meets the
				requirements in Paragraph (2) above, the lenses may be replaced when there is a
				minimum 0.75 diopter change in the prescription. The combined refractive error
				of sphere and cylinder to equal 0.75 will be accepted. An exception is
				considered for the following:
(i) a MAP
				eligible recipient over 21 years of age with cataracts;
(ii) an ophthalmologist or optometrist
				recommends a change due to a medical condition; or
(iii) a MAP eligible recipient is under 21
				years of age.
(3) Bifocal lenses: MAD covers bifocal lenses
				with a correction of 0.25 or more for distance vision and 1 diopter or more for
				added power (bifocal lens correction).
(4) Tinted lenses: MAD covers tinted lenses
				with filtered or photochromic lenses if the examiner documents one or more of
				the following disease entities, injuries, syndromes or anomalies in the
				comments section of the visual examination record, and the prescription meets
				the dioptic correction purchase criteria:
(a)
				aniridia;
(b) albinism,
				ocular;
(c) traumatic defect in
				iris;
(d) iris coloboma,
				congenital;
(e) chronic
				keratitis;
(f) sjogren's
				syndrome;
(g) aphakia, U.V. filter
				only if intraocular lens is not U.V. filtered;
(h) rod monochromaly;
(i) pseudophakia; or
(j) other diagnoses confirmed by
				ophthalmologist or optometrist that is documented in the MAP eligible
				recipient's visual examination form.
(5) Polycarbonate lenses: MAD covers
				polycarbonate lenses for:
(a) a MAP eligible
				recipient for medical conditions which require prescriptions for high power
				lenses;
(b) a MAP eligible
				recipient with monocular vision;
(c) a MAP eligible recipient who works in a
				high-activity physical job;
(d) a
				MAP eligible recipient under 21 years of age; or
(e) a MAP eligible recipient 21 years and
				older that has a developmental or intellectual disability.
(6) Balance lenses: MAD covers balance lenses
				for a MAP eligible recipient under 21 years of age without a prior
				authorization in the following situations:
(a)
				lenses used to balance an aphakic eyeglass lens; or
(b) a MAP eligible recipient under 21years of
				age is blind in one eye and the visual acuity in the eye requiring correction
				meets the diopter correction purchase criteria.
(7) Frames: MAD covers frames for corrective
				lenses. Coverage for a MAP eligible recipient 21 years of age and older is
				limited to one frame in a 36-month period. If a MAP eligible recipient has
				transitioned from the EPSDT program at age 21, the date of service of his or
				her last frames starts the 36-month period. Coverage for a MAP eligible
				recipient under 21 years of age is limited to one frame in a 12-month period
				unless:
(a) an ophthalmologist or optometrist
				has documented a medical condition that requires replacement; or
(b) other situations that will be reviewed on
				a case-by-case basis.
(8) Contact lenses: MAD covers contact
				lenses, either the original prescription or replacement, only with a prior
				authorization. Coverage for an eligible adult recipient 21 years of age and
				older is limited to one pair of contact lenses in a 24-month period, unless an
				ophthalmologist or an optometrist recommends a change in prescription due to a
				medical condition affecting vision. If a MAP eligible recipient is transition
				from the EPSDT program at age 21, the date of service for his or her last
				contact lenses starts as the 24-month period. A request for prior authorization
				will be evaluated on dioptic criteria or visual acuity, the MAP eligible
				recipient's social or occupational need for contact lenses, and special medical
				needs. The criteria for authorization of contact lenses are as follows:
(a) the MAP eligible recipient must have a
				diagnosis of keratoconus or diopter correction of +/- -6.00 or higher in any
				meridian or at least 3.00 diopters of anisometropia; or
(b) monocular aphakics may be provided with
				one contact lens and a pair of bifocal glasses.
(9) Replacement: Eyeglasses or contact lenses
				that are lost, broken or have deteriorated to the point that, in the examiner's
				opinion, they have become unusable to the MAP eligible recipient, may be
				replaced. Two items must be documented in the provider's request for the
				replacement in addition to being found in the MAP eligible recipient's visual
				examination record: The MAP eligible recipient's eyeglasses or contact lens (or
				lenses) must meet the diopter correction purchase criterion; and an explanation
				of the loss, deterioration or breakage is provided. The following are the
				criteria that an MAP eligible recipient must be meet for the replacement of his
				or her eyeglasses or contact lenses:
(a) the
				MAP eligible recipient is under 21 years of age; or
(b) the MAP eligible recipient is 21 years of
				age and older and has a developmental or intellectual disability.
(10) Prisms: Prisms are covered if
				medically indicated to prevent diplopia (double vision). Documentation is
				required on the MAP eligible recipient's visual examination record.
(11) Lens tempering: MAD covers lens
				tempering only on new glass lenses.
(12) Lens edging: MAD covers lens edging and
				lens insertion.
(13) Minor repairs:
				MAD covers minor repairs to eyeglasses.
(14) Dispensing fee: MAD pays a dispensing
				fee to an ophthalmologist, optometrist, or optician for dispensing a
				combination of lenses and new frames at the same time. This fee is not paid
				when contact lenses are dispensed. The prescription and fitting of contact
				lenses is paid to dispensing ophthalmologists and optometrists. Independent
				technicians are not approved by MAD to prescribe and fit contact
				lenses.
(15) Eye prosthesis: MAD
				covers eye prostheses (artificial eyes); see Subsection D below.