NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).
Refractive lenses are covered under the prosthetic devices benefit category (Social Security Act §1861(s)(8)). In order for a beneficiary’s equipment to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.
Refractive lenses are covered when they are used to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence. Covered diagnoses are limited to pseudophakia (condition in which the natural lens has been replaced with an artificial intraocular lens [IOL]), aphakia (condition in which the natural lens has been removed but there is no IOL), and congenital aphakia. Lenses provided for other diagnoses will be denied as noncovered.
Refractive lenses are covered even though the surgical removal of the natural lens occurred before Medicare entitlement.
For beneficiaries with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL. Replacement frames, eyeglass lenses and contact lenses are noncovered. If a beneficiary has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, Medicare covers only one pair of eyeglasses or contact lenses after the second surgery. If a beneficiary has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye).
Refer to the Local Coverage Determination (LCD) for information about coverage of lenses for aphakic beneficiaries (i.e., those who do not have an IOL).
Because coverage of refractive lenses is based upon the Prosthetic Device benefit category, there is no coverage for frames or lens add-on codes unless there is a covered lens(es). Frames provided without a covered lens(es) will be denied as noncovered.
Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as noncovered.
Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered.
Use of polycarbonate or similar material (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature.
Specialty occupational multifocal lenses (V2786) will be denied as noncovered.
Only standard frames (V2020) are covered. Additional charges for deluxe frames (V2025) will be denied as noncovered.
When hydrophilic soft contact lenses (V2520, V2521, V2522, V2523) are used as a corneal dressing, they are denied as noncovered because in this situation they do not meet the definition of a prosthetic device.
Eyeglass cases (V2756) will be denied as noncovered.
Contact lens cleaning solution and normal saline for contact lenses will be denied as noncovered.
Low vision aids (V2600, V2610, V2615) will be denied as noncovered because coverage under the Medicare prosthetic benefit is limited to persons with congenital absence or surgical removal of the lens of the eye.
Vision supplies, accessories, and/or service components of another HCPCS vision code (V2797) will be denied as not separately payable.
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
The diagnosis code that justifies the need for these items must be included on the claim.
CONTINUED MEDICAL NEED
For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, unless continued coverage requirements are specified in the LCD, ongoing need for the lens(es) is assumed to be met. There is no requirement for further documentation of continued medical need as long as the beneficiary continues to meet the prosthetic devices benefit.
KX, GA, GY and GZ MODIFIERS:
For anti-reflective coating (V2750), tints (V2744, V2745) or oversized lenses (V2780), if medical necessity is documented by the treating practitioner, the KX modifier must be added to the code. For polycarbonate or Trivex TM lenses (V2784), if they are for a beneficiary with monocular vision, the KX modifier must be added to the code. The KX modifier may only be used when these requirements are met. When the KX modifier is billed, documentation to support the medical necessity of the lens feature must be available upon request.
For anti-reflective coating (V2750), polycarbonate or Trivex TM lenses (V2784), tints (V2744, V2745) or oversized lenses (V2780), if the coverage criteria have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.
Claim lines for anti-reflective coating (V2750), tints (V2744, V2745), oversized lenses (V2780) or polycarbonate or Trivex TM lenses (V2784) billed without a KX, GA, GY or GZ modifier will be rejected as missing information.
Refer to the Supplier Manual for more information on documentation requirements.
Deluxe lens features (V2702) include services and features such as lens edge treatments and lens drilling.
Photochromatic lenses (V2744) and contacts (V2524) are those in which the degree of tint changes in response to changes in ambient light. Code V2744 is used for any type of photochromatic lens, either glass or plastic. Code V2524 is used for any type of photochromatic contact lens.
Code V2745 is used for any type or color of lens tint, excluding photochromatic lenses.
Code V2755 must be used only if a UV coating is applied to a lens and not as an add-on code for the UV protection inherent in the lens material.
Anti-reflective coating (V2750) is a clear lens treatment used to decrease glare and internal/external reflections.
Mirror coatings (V2761) are colored, highly reflective lens treatments.
Progressive lens (V2781) is a multifocal lens that gradually changes in lens power from the top to the bottom of the lens, eliminating the line(s) that would otherwise be seen in a bifocal or trifocal lens.
Code V2784 is an add-on used for lenses made of impact-resistant material such as polycarbonate or Trivex TM. Codes V2782 and V2783 (high index) must not be billed in addition to code V2784.
Codes V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2399, V2410, V2430, V2499, V2700, and V2770 describe specific eyeglass lenses. Only one of these codes may be billed for each lens provided. These codes include both aspheric and nonaspheric lenses.
Codes V2115, V2118, V2121, V2215, V2218, V2219, V2220, V2221, V2315, V2318, V2319, V2320, V2321, V2710, V2715, V2718, V2730, V2744, V2745, V2750, V2755, V2756, V2760, and V2780, V2781, V2782, V2783, V2784, V2786, V2797 describe add-on features of lenses. They are billed in addition to codes for the basic lens.
When billing claims for deluxe frames, use code V2020 for the cost of standard frames and a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames.
When billing claims for progressive lenses, use the appropriate code for the standard bifocal (V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221, V2299) or trifocal (V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, V2321, V2399) lenses and a second line item using code V2781 for the difference between the charge for the progressive lens and the standard lens.
The RT and/or LT modifiers must be used with all HCPCS codes in this policy except codes V2020, V2025 and V2600. Effective for claims with dates of service (DOS) on or after 3/1/2019, when lenses are provided bilaterally and the same code is used for both lenses, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.
PROSE® (BostonSight, Needham, MA) devices are designed to rest on the sclera or white part of the eye and are used to treat ocular surface diseases, including some types of "dry eye." For Medicare billing purposes correct HCPCS coding for this item is determined based upon the condition(s) being treated. When the PROSE® device is used as a treatment for either of the following indications listed below, the correct HCPCS code to use is V2627 (SCLERAL COVER SHELL):
Treatment of an eye rendered sightless and shrunken by inflammatory disease; or,
Treatment of "dry eye" where the PROSE® device serves as a substitute for the function of the diseased lacrimal gland.
When the PROSE® device is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531 (CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)) and is subject to the Medicare refractive lens statutory coverage exclusion.
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)Contractor for guidance on the correct coding of these items.