Medicine
Chapter 7
Section 6.2
Lenses (Intraocular Or Contact) And Eye
Glasses
Issue Date: January
23, 1984
Copyright: CPT only © 2006
American Medical Association (or such other date of publication
of CPT).
All Rights Reserved.
Revision: C-1,
March 10, 2017
1.0 CPT PROCEDURE
CODES
92310 - 92326
2.0 POLICY
2.1 Lenses must
be
either approved for marketing by the U.S.
Food and Drug Administration (FDA)
or subject to an
Investigational Device Exemption (IDE).
See Chapter 8, Section 5.1.
2.2 Lenses
or eye glasses are only cost-shared for the following conditions:
• Contact lenses for treatment of infantile
glaucoma.
• Corneal or scleral
lenses for treatment of keratoconus.
• Scleral lenses to retain moisture when
normal tearing is not present or is inadequate.
• Corneal or scleral lenses prescribed to
reduce a corneal irregularity other than astigmatism.
• Intraocular lenses (IOL),
contact lenses, or eyeglasses to perform the function of the human lens,
lost as the result of intraocular surgery or ocular injury or congenital
absence. Benefits for the IOL for this condition are
limited to the standard fixed non-accommodating monofocal IOL, (V2630,
V2631, V2632).
2.3 Benefits are
also specifically limited to
one set of
lenses
related to one of the qualifying eye conditions
listed in paragraph 2.2. A set may also include a combination
of both lenses and eyeglasses when a combination is necessary
and
related to one of the qualifying eye conditions.
2.4 When there is
a prescription change still related to the qualifying eye condition,
a new set may be cost-shared, subject to medical review.
2.5 Reimbursement
for a standard monofocal IOL covered under paragraph 2.2 is
packaged into the payment for the extraction and lens implantation
performed in a hospital on either an inpatient basis subject to
the Diagnosis Related Group (DRG) reimbursement system (see the
TRICARE Reimbursement Manual (TRM), Chapter 6, Section 4, paragraph 3.2)
or outpatient basis subject to Outpatient Prospective Payment System
(OPPS) (see the TRM, Chapter 13, Section 3, paragraph 3.6.4.3) or
in an Ambulatory Surgical Center (ASC) (see the TRM, Chapter 6, Section 4, paragraph 3.2).
For a standard monofocal IOL inserted in a physician’s office, payment
for the IOL is based upon the allowable charge basis.
3.0 EXCLUSIONS
3.1 When the prescription
remains unchanged, replacement for lenses that are lost, have deteriorated
or that have become unusable due to physical growth are not
covered.
3.2 Adjustments,
cleaning, or repairs of glasses are not covered (Current Procedural
Terminology (CPT) procedure codes 92340 - 92371).
3.3 Astigmatism-Correcting
Intraocular Lenses (A-C IOL) (V2787) and Presbyopia-Correcting Intraocular
Lenses (P-C IOL) (V2788) are excluded from TRICARE coverage. Any
adjustments, subsequent treatment, services or supplies required
to examine and monitor the beneficiary who receives an A-C IOL or
P-C IOL are also excluded. These items are excluded and the beneficiary
is responsible for costs associated with these excluded lenses.
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