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-107, January 6, 2023
1.0 CPT PROCEDURE CODES
92310 - 92326
2.0 POLICY
2.1 Lenses
must be either approved for marketing by the
United
States (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, and 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 are 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 9, Section 1) 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 is not
covered for lenses that are lost, have deteriorated
or that have become unusable due to physical growth.
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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