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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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