Download Contact Lenses for Medicaid, Child Health Plus and Family Health

MEDICAL POLICY
SUBJECT: CONTACT LENSES FOR MEDICAID,
CHILD HEALTH PLUS, FAMILY
HEALTH PLUS CONTRACTS
POLICY NUMBER: 9.01.12
CATEGORY: Contract Clarification
EFFECTIVE DATE: 06/23/05
REVISED DATE: 06/22/06, 06/28/07, 06/26/08, 06/25/09,
06/24/10, 06/24/11, 06/28/12, 06/27/13,
06/26/14, 06/25/15
PAGE: 1 OF: 3
Note: If the member's subscriber contract excludes coverage for a specific service it is not covered under that
contract. In such cases medical policy criteria are not applied.
Note: Criteria for Family Health Plus members pertain to services rendered prior to 1/1/15.
POLICY STATEMENT:
I.
Contact lenses are considered medically necessary for any of the following indications:
A. Congenital aphakia;
B. Acquired aphakia after cataract surgery (adult and pediatric);
C. Irregular corneas/corneal scarring when vision can not be corrected with spectacles (e.g., keratoconus, post
corneal graft surgery, post corneal infection);
D. As a corneal bandage to promote wound healing (e.g., corneal ulcer/erosion, keratitis); or
E. Refractive errors that cannot be achieved to an acuity level of 20/40 with eyeglasses.
II. Contact lenses are considered not medically necessary for the following conditions:
A. Albinism- as an alternative to tinted glasses to reduce severe light sensitivity or photophobia;
B. Amblyopia- as an alternative to traditional eye patching/occlusion therapy; or
C. Correction of refractive errors in lieu of eyeglasses except as stated above.
POLICY GUIDELINES:
I.
Prior approval is required for all contact lens service.
II. Contact lenses utilized in the treatment of a medical condition of the eye are covered under the Eye Care and Low
Vision Services benefit for Medicaid, Family Health Plus and Child Health Plus members.
A. Contact lenses for Medicaid members are eligible for coverage once every 24 months, unless there has been a
change in vision warranting a change in prescription or the lenses are lost or damaged.
B. Contact lenses for Family Health Plus members are eligible for coverage once every 24 months.
C. Contact lenses for Child Health Plus members are eligible for coverage once every 12 months.
III. Multiple contact lens changes may be required in pediatric patients with either acquired or congenital aphakia.
IV. Request for contact lens must include all of the following:
A. Medical necessity documentation;
B. Best corrected vision both with and without eyeglasses;
C. Best corrected vision both with and without contact lens;
D. Date of last complete eye exam; and
E. Refractive error.
DESCRIPTION:
Contact lenses are small plastic discs that are placed directly on the eye, where they float on a film of tears in front of the
cornea. There are several types of contact lenses. Hard (rigid) lenses, rigid gas-permeable and soft (hydrogel) lenses are
the most commonly prescribed. Contact lenses are usually worn as an alternative to spectacles (eyeglasses) to correct a
refractive error such as nearsightedness, farsightedness or astigmatism, but may also be worn to correct a variety of
medical conditions involving the eye.
RATIONALE:
Unlike the eye of an adult patient with aphakia, a child’s eye continues to grow. As the eye length increases, the power
needed to correct the child’s vision will decrease. This causes frequent changes in a child’s contact lens. Infants typically
require a change in contact lens fit at 6-8 weeks old, 6-9 months and around 1 year old. After 1 year of age, a child is
Proprietary Information of Excellus Health Plan, Inc.
A nonprofit independent licensee of the BlueCross BlueShield Association
SUBJECT: CONTACT LENSES FOR MEDICAID,
CHILD HEALTH PLUS, FAMILY
HEALTH PLUS CONTRACTS
POLICY NUMBER: 9.01.12
CATEGORY: Contract Clarification
EFFECTIVE DATE: 06/23/05
REVISED DATE: 06/22/06, 06/28/07, 06/26/08, 6/25/09,
06/24/10, 06/24/11, 06/28/12,
06/27/13, 06/26/14, 06/25/15
PAGE: 2 OF: 3
seen less frequently, every 2-3 months, and requires fewer changes. The average child goes through 8 lenses per eye
during the first year and 4 lenses per eye, thereafter, including fit changes, loss and breakage.
Keratoconus, an irregular protrusion of the cornea is a slowly progressive condition often presenting in the teens or early
twenties. During the early stages of this disease, vision may still be correctable with glasses. As the cornea steepens and
becomes more irregular, glasses are no longer capable of providing adequate visual improvement. Nearly 90% of
patients with progressive keratoconus can be managed indefinitely with gas permeable contact lenses.
CODES:
Number
Description
Eligibility for reimbursement is based upon the benefits set forth in the member’s subscriber contract.
CODES MAY NOT BE COVERED UNDER ALL CIRCUMSTANCES. PLEASE READ THE POLICY AND
GUIDELINES STATEMENTS CAREFULLY.
Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently than policy updates.
CPT:
92071
Fitting of contact lens for treatment of ocular surface disease
92072
Fitting of contact lens for management of keratoconus, initial fitting
92310-92326
Contact lens services (code range)
Copyright © 2015 American Medical Association, Chicago, IL
HCPCS:
V2500-V2599
Contact lens (code range)
ICD9:
366.00-.09
Infantile, juvenile and presenile cataract
366.10-.19
Senile cataract
366.9
Unspecified cataract
370.20-.24
Keratitis code range
370.00-370.07
Corneal ulcer code range
371.00-.04
Corneal scar code range
371.60-371.62
Keratoconus code range
371.70-.73
Corneal deformity
379.31
Aphakia
743.30-.34
Congenital cataract and lens anomalies code range
743.35
Congenital aphakia
H16.00-H16.079
Corneal ulcer (code range)
H16.101- H161.49
Keratitis (code range)
H17.00-H17.03
Adherent leukoma (code range)
H17.10-H17.829
Corneal opacity (code range)
H17.89
Other corneal scars and opacities
H17.9
Unspecified corneal scar and opacity
H18.601-H18.629
Keratoconus (code range)
H187.11-H187.19
Corneal ectasia (code range)
ICD10:
Proprietary Information of Excellus Health Plan, Inc.
SUBJECT: CONTACT LENSES FOR MEDICAID,
CHILD HEALTH PLUS, FAMILY
HEALTH PLUS CONTRACTS
POLICY NUMBER: 9.01.12
CATEGORY: Contract Clarification
EFFECTIVE DATE: 06/23/05
REVISED DATE: 06/22/06, 06/28/07, 06/26/08, 6/25/09,
06/24/10, 06/24/11, 06/28/12,
06/27/13, 06/26/14, 06/25/15
PAGE: 3 OF: 3
H187.21-H187.29
Corneal staphyloma (code range)
H187.31-H187.39
Descemetocele (code range)
H187.91-H187.99
Other corneal deformities (code range)
H25.011- H25.9
Age-related cataract (code range)
H26.001-H26.09
Infantile and juvenile cataract (code range)
H26.9
Unspecified cataract
H27.00-H27.03
Aphakia (code range)
Q12.3
Congenital aphakia
REFERENCES:
American Academy of Ophthalmology. Preferred Practice Pattern. Refractive errors.
[http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=e6930284-2c41-48d5-afd2-631dec586286] accessed
5/21/13.
American Association for Pediatric Ophthalmology and Strabismus. Policy statement. Aphakic lenses.
[http://www.aapos.org/resources/policy_satements/] accessed 5/15/14.
Ehlers WH, et al. Visual rehabilitation in children with cataracts. Can J Ophthalmol 2011 Oct;46(5):439-40.
Infant Aphakia Treatment Study group, et al. A randomized clinical trial comparing contact lens with intraocular lens
correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year. Arch Ophthalmol 2010
Jul;128(7):810-8.
*Joslin CE, et al. The effectiveness of occluder contact lenses in improving occlusion compliance in patients that have
failed traditional occlusion therapy. Optom Vis Sci 2002 Jun;79(6):376-80.
*Kanpolat A, et al. Therapeutic use of Focus Night and Day contact lenses. Cornea 2003 Nov;22(8):726-34.
*Lambert SR. et al. A comparison of grating visual acuity, strabismus, and reoperation outcomes among children with
aphakia and pseudoaphakia after unilateral cataract surgery during the first six months of life. JAAPOS 2001
Apr;5(2):70-5.
*Lambert SR, et al. Intraocular lens implantation during infancy: perceptions of parents and the American Association
for Pediatric Ophthalmology and Strabismus members. JAAPOS 2003 Dec;7(6):400-5.
*Ma JJ, et al. Contact lenses for the treatment of pediatric cataracts. Ophthalmol 2003 Feb;110(2):299-305.
Optometric Practice Guideline. Care of the contact lens patient. American Optometric Association Consensus Panel.
[http://www.aoa.org/documents/CPG-19.pdf] accessed 5/15/14.
Ventocilla M OD, et al. Specialty Contact Lenses. [http://emedicine.medscape.com/article/1222353-overview] accessed
5/15/14.
*Watson SL, et al. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2007 Oct
17;(4):CD0011861.
Proprietary Information of Excellus Health Plan, Inc.