Download Determination of Refractory State retire 1-1-14

MEDICAL POLICY
POLICY TITLE
DETERMINATION OF REFRACTORY STATE
POLICY NUMBER
MP-4.015
Original Issue Date (Created):
July 10, 2002
Most Recent Review Date
(Revised):
November 26, 2013
Effective Date:
January 1, 2014 RETIRED
I. POLICY
Determination of refractive state may be considered medically necessary when performed
to monitor or assess the progression of a medical condition (such as treatment of primary
congenital glaucoma or surgical/congenital aphakia).
Cross-reference
MP-2.028 Eye Care
MP-6.031 Corneal Liquid Bandage Lens
II. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids
[N] Indemnity
[N] PPO
[N] SpecialCare
[Y] HMO*
[N] POS
[Y] FEP PPO*
[Y] SeniorBlue PPO**
[Y] SeniorBlue**
*Vision services (testing, treatment, and supplies): Benefits are limited to one pair of
eyeglasses, replacement lenses, or contact lenses per incident prescribed:
 To correct an impairment directly caused by a single instance of accidental ocular
injury or intraocular surgery.

In lieu of surgery when the condition can be corrected by surgery, but surgery is
precluded because of age or medical condition.

For the nonsurgical treatment for amblyopia and strabismus, for children from birth
through age 18
NOTE: Benefits are provided for refractions only when the refraction is performed to
determine the prescription for the one pair of eyeglasses, replacement lenses, or contact
lenses provided per incident as described above.
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MEDICAL POLICY
POLICY TITLE
DETERMINATION OF REFRACTORY STATE
POLICY NUMBER
MP-4.015
** Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye
refractions by whatever practitioner and for whatever purpose performed may not be
covered. Refer to member’s individual or group benefit information to determine
coverage. This does not apply to services performed in conjunction with an eye disease.
Refer to Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy
Manual. Publication 100-02. Chapter 16. Section 90. General Exclusions from Coverage.
III. DESCRIPTION/BACKGROUND
The term refractive error is used when the eye does not bend light to converge properly,
thereby producing a blurred image. To determine the degree of the refractive error, an
exam is performed by interposing different lenses in front of the eye until the greatest
visual acuity is achieved. This exam is generally performed for purposes of prescribing
corrective lenses. Refractive errors are eye disorders, but are not diseases.
However, there are instances when a patient’s vision is impacted by a medical condition
that can affect the ocular system. Some medical conditions (e.g. diabetes, macular
degeneration, glaucoma, and other systemic diseases) can affect the ocular system and
impact vision. Refraction can be performed to evaluate and monitor these conditions.
Primary congenital glaucoma remains the most frequent childhood glaucoma and an
important cause of blindness. Thorough examinations to include refraction of children
with primary congenital glaucoma are required to differentiate this condition from other
types of childhood glaucoma in preparation for surgery and progressive treatment.
IV. DEFINITIONS
APHAKIA is an ophthalmologic condition in which part or all of the crystalline lens is
absent,usually because it has been surgically removed as in the treatment of cataracts.
CONGENITAL refers to something that is present at birth.
GLAUCOMA is a multifactorial optic neuropathy in which there is a characteristic acquired
loss of optic nerve fibers.
V. BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
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MEDICAL POLICY
POLICY TITLE
DETERMINATION OF REFRACTORY STATE
POLICY NUMBER
MP-4.015
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
VI. DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not
constitute medical advice and are subject to change. Treating providers are solely responsible for
medical advice and treatment of members. Members should discuss any medical policy related to
their coverage or condition with their provider and consult their benefit information to determine if
the service is covered. If there is a discrepancy between this medical policy and a member’s benefit
information, the benefit information will govern. Capital considers the information contained in
this medical policy to be proprietary and it may only be disseminated as permitted by law.
VII. REFERENCES
American Optometric Association: What is 20/20 Vision? [Website]:
http://www.aoa.org/x4695.xml Accessed August 31, 2012.
Casser L, Carmiencke K, Goss D, et al. American Optometric Association. Optometric
Clinical Practice Guideline. Comprehensive Adult Eye and Vision Examination. April
28, 2005. [Website]: http://www.aoa.org/documents/CPG-1.pdf Accessed August 31,
2012.
Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual.
Publication 100-02. Chapter 16. Section 90. General Exclusions from Coverage.
10/01/03. [Website]: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf.
Accessed August 31, 2012.
Coats D, Paysse E. Refractive errors in Children. In: UpToDate Online Journal [serial
online]. Waltham, MA: UpToDate; updated April 17, 2012. [Website]:
www.uptodate.com . Accessed August 31, 2012. FEP Blue Cross and Blue Shield
Service Benefit Plan 2012 Brochure. [Website]:
http://www.fepblue.org/benefitplans/2012-sbp/bcbs-2012-RI71-005.pdf Accessed
August 31, 2012.
Scheiman M, Amos C, Ciner E, et al. American Optometric Association. Optometric
Clinical Practice Guideline. Pediatric Eye and Vision Examination. 2002. [Website]:
http://www.aoa.org/documents/CPG-2.pdf . Accessed August 31, 2012.
Taber’s Cyclopedic Medical Dictionary, 19th edition.
The University of Michigan Kellogg Eye Center. Patient Education: Refractive
Errors.Updated 2012 [Website]:
http://www.kellogg.umich.edu/patientcare/conditions/refractive.errors.html. Accessed
August 31, 2012.
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MEDICAL POLICY
POLICY TITLE
DETERMINATION OF REFRACTORY STATE
POLICY NUMBER
MP-4.015
VIII. CODING INFORMATION
Note: This list of codes may not be all-inclusive, and codes are subject to change at any
time. The identification of a code in this section does not denote coverage as coverage is
determined by the terms of member benefit information. In addition, not all covered
services are eligible for separate reimbursement.
Covered when medically necessary:
CPT
Codes ®
92015
Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.
HCPCS
Code
S0620
S0621
ICD-9-CM
Diagnosis
Code*
365.41 –
365.44
366.50 –
366.53
Description
ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW
PATIENT
ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION;
ESTABLISHED PATIENT
Description
GLAUCOMA ASSOCIATED WITH CONGENITAL ANOMALIES, DYSTROPHIES, AND SYSTEMIC
SYNDROMES
AFTER – CATARACT ( APHAKIA)
379.31
APHAKIA
743.20 –
743.22
Buphthalmos, unspecified
743.35
CONGENITAL APHAKIA
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MEDICAL POLICY
POLICY TITLE
DETERMINATION OF REFRACTORY STATE
POLICY NUMBER
MP-4.015
The following ICD-10 diagnosis codes will be effective October 1, 2014
ICD-10-CM
Diagnosis Description
Code*
H40.89
OTHER SPECIFIED GLUCOMA
H27.00 –
H27.03
APHAKIA (CODE RANGE)
H26.40
AFTER CATARACT UNSPECIFIED
H26.411 –
H26.419
SOEMMERING’S RING (CODE RANGE)
Q15.0
CONGENITAL GLAUCOMA
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
IX. POLICY HISTORY
MP 4.015
CAC 4/27/04
CAC 12/14/04
CAC 2/22/05
CAC 1/31/06
CAC 1/30/07
CAC 3/25/08
CAC 1/27/09 Consensus
CAC 1/26/10 Consensus Review. No change in policy statement. References
updated.
CAC 4/26/11 Consensus review.
CAC 10/30/12 Consensus review. No change in policy statement. References
updated. FEP variation revised to reflect FEP benefit plan brochure regarding
indications for which this procedure would be provided. Codes added to policy
10/26/12
CAC 11/26/13 Policy will be retired – Effective 1/1/2014 (Title corrected)
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ®,
Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
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