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:
1.0 CPT CODES
92310 - 92326
2.0 POLICY
2.1 Lenses
must be either approved for marketing by the United States (US)
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) or outpatient basis
subject to Outpatient Prospective Payment System (OPPS) (see the
TRM,
Chapter 13, Section 3) or in an Ambulatory
Surgical Center (ASC) (see the TRM,
Chapter 9, Section 1). 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) 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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