Lenses

Affected Providers

Physicians and non-physician practitioners who write prescriptions or orders for lenses.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Refractive Lenses (L33793) and Article: Refractive Lenses (A52499) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for lenses is 65.9%, with a projected improper payment amount of $15.7 million.

We outline other policy requirements in LCD L33793 and Article A52499.

Denial Reasons

Insufficient documentation accounted for 32.7% of improper payments for lenses during the 2024 reporting period, while medical necessity (23.6%), no documentation (4.2%), and other errors (39.5%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We cover refractive lenses when they restore vision normally given by the eye’s natural lens for people without the organic lens because of surgical removal or congenital absence. We only cover refractive lenses for patients who don’t have a natural lens that works.

We limit covered diagnoses to: 

• Pseudophakia, a condition when an artificial intraocular lens (IOL) replaces the natural lens;
• Aphakia, a condition when the Medicare provider removed the natural lens but there’s no IOL
• Congenital aphakia, a congenital absence of lens

We deny lenses provided for other diagnoses as non-covered.

Follow these policy criteria when billing Medicare for lenses:

• We cover these lenses, or combination of lenses, when you find lenses medically necessary for patients who are aphakic (patients who had a cataract removed but don’t have an IOL or who have congenital absence of lens):
  • Bifocal lenses in frames
  • Lenses in frames for either far or near vision
  • Contact lenses for far vision — when a health care provider prescribes them (including cases of binocular and monocular aphakia) — plus lenses in frames for near vision for patients to wear at the same time as contact lenses, and lenses in frames for the patient to wear when the patient removes the contacts
• For aphakic patients, we cover replacement lenses when they’re medically necessary
• We cover anti-reflective coating (HCPCS code V2750), tints (HCPCS codes V2744 and V2745), or oversize lenses (HCPCS code V2780) only when they’re medically necessary for the patient, and the treating practitioner documents medical necessity. When you provide these features as a patient preference item and bill them with an EY modifier (see Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)), we deny them as not reasonable and necessary.
• We consider ultraviolet (UV) protection as reasonable and necessary after cataract extraction, so the treating practitioner doesn’t need to include other medical necessity justification on the order. We deny claims for adding UV coating (HCPCS code V2755) as not reasonable and necessary for polycarbonate lenses (HCPCS code V2784)
• We deny tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses and prescriptions to regular prosthetic lenses to an aphakic patient as not reasonable and necessary.
• We cover lenses made of polycarbonate or other impact-resistant materials (V2784) only for patients with working vision in only 1 eye. In this situation, we cover an impact-resistant material for both lenses if we cover eyeglasses. We deny claims for V2784 that don’t meet this coverage criterion as not reasonable and necessary.
• For patients with pseudophakia, coverage is limited to 1 pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL. We don’t cover replacement frames, eyeglass lenses, and contact lenses. Article A52499 has more information.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Lenses

A supplier bills the claim for HCPCS code V2780 (Oversize lens, per lens) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that doesn’t have medical necessity information
• Proof of delivery

What Documentation Was Missing?

The practitioner didn’t document medical necessity.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To avoid billing errors and improper payments, the certifying physician must collect and submit proper documentation, including medical necessity, in the treating practitioner’s medical record for DMEPOS.