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Aetna Aetna
Clinical Policy Bulletin:
Contact Lenses and Eyeglasses
Number: 0126


Policy

Note: Many Aetna medical plans exclude coverage of contact lenses or eyeglasses.  Under medical plans with this exclusion, contact lenses are only covered under medical plans for a narrow set of therapeutic indications, as outlined below.  Additional coverage of contact lenses and eyeglasses may be provided under the member's vision care plan, if any.  Please check benefit plan descriptions for details.

  1. Replacement Eyeglasses Under Plans With a Pediatric Vision Benefit

    Some plans include a pediatric vision benefit. Please check benefit plan descriptions. Under these plans, replacement lenses are considered medically necessary for children and adolescents when one or more of the following criteria are met:

    1. There is a change in refractive error; or

    2. With regular use, the previous eyeglasses were broken or marred to a degree significantly interfering with vision or eye safety; or

    3. The eyeglasses are replaced because a different frame size or shape is necessary due to the child's growth, metal allergy or other justifiable medical reasons.

  2. Prosthetic Contact Lenses and Eyeglasses for Aphakia

    1. Medicare plans and HMO plans (HMO, QPOS)

      For Aetna Medicare plans and Aetna HMO plans, Aetna follows Medicare's rules for prosthetic lenses.

      For Aetna Medicare members and HMO members, Aetna considers external lenses (contacts or spectacles) and intraocular lenses medically necessary after cataract surgery.  Centers for Medicare and Medicaid Services (CMS) defines both types of lenses as “prostheses” replacing the lens of the eye.  This includes post-surgical external lenses that are customarily used during convalescence from cataract removal surgery.  In addition, an intraocular lens is considered a medically necessary prosthetic for individuals lacking an organic lens because of surgical removal (e.g., cataract surgery) or congenital absence (congenital aphakia).  Note: Aetna covers medically necessary external and internal lenses as prosthetics for aphakic members even if the surgical removal of the member's lens occurred before the member enrolled in Aetna's medical plan.

      For Medicare and HMO members, Aetna considers lenses or combinations of lenses medically necessary following cataract surgery to essentially restore the vision provided by the crystalline lens of the eye, including:

      • Bifocal spectacles; or
      • Spectacles for far vision or for near vision; or
      • Aetna considers contact lenses for far vision (including cases of binocular and monocular aphakia) medically necessary, including both the contact lens(es) and spectacles for near vision that are worn either simultaneously with the contact lenses or when the contact lenses have been removed.

      For Medicare members and HMO members, Aetna medical plans consider  lenses with ultraviolet (UV) protection medically necessary in lieu of regular (untinted) lenses for aphakia.  UV coating is considered medically necessary when applied to a glass lens material.

      Anti-reflective coating, tints, or oversize lenses are not generally considered medically necessary; the medical necessity of such features must be documented by the treating physician.

      Aetna considers cataract sunglasses (i.e., tinted lenses, including photochromatic lenses (lenses in which the tint changes in response to light)) that are prescribed in addition to regular (untinted) lenses for aphakia medically necessary because the sunglasses duplicate the restoration of vision function performed by the regular lenses.

      Aetna considers the following features not medically necessary:

      • Eyeglass cases;
      • Mirror coating (colored, highly-reflective lens treatments);
      • Polarization;
      • Progressive lenses (i.e., multifocal lens that gradually changes in lens power from the top to the bottom of the lens, eliminating the lines that would otherwise be seen in a bifocal or trifocal lens);
      • Scratch resistant coating.

      Lenses made of polycarbonate or other impact-resistant materials (e.g., Trivex) are considered medically necessary for members with functional vision in only one eye.  Use of polycarbonate or similar material or high index glass or plastic for indications such as light weight or thinness is considered not medically necessary.

      Standard eyeglass frames are considered medically necessary for persons who meet criteria for refractive lenses.  Deluxe frames are considered convenience items.

      Under Medicare and HMO plans, Aetna considers eyewear a medically necessary prosthetic for aphakic members who have not had an intraocular lens replacement.  Since these members lack an internal lens, their contact lenses or eyeglasses are considered to be prosthetics.  For Medicare and HMO plans, Aetna medical plans consider medically necessary the first pair of glasses or aphakia contact lenses after cataract surgery and an additional pair of lens(es) each time the member's prescription changes.  Requests for replacement of lost or broken glasses or lenses will be reviewed on an individual basis.  (There is a CMS requirement for consideration of replacement of lost or broken contact lenses or eyeglasses for Medicare members who have had cataract surgery.)

      Note: For Medicare and HMO members who have had cataract surgery with insertion of an intraocular lens (IOL), Aetna Medicare and HMO plans, by administration, will cover no more than 1 pair of eyeglasses or contact lenses after each cataract surgery.  Replacements of conventional eyeglasses or contact lenses are not covered under these medical plans.  The member may have additional eyewear coverage through a vision care rider.

    2. Traditional (non-HMO) plans (Indemnity, PPO and MC POS plans)

      While contact lenses and eyeglasses are rarely used in place of intraocular lenses in aphakia, contact lenses and eyeglasses are considered medically necessary under traditional medical plans as a prosthetic device following cataract surgery in lieu of intraocular lenses.  Note: Most Aetna plans exclude coverage of contact lenses and spectacles.  Under these plans, eyeglasses and contact lenses in non-aphakic members, including those who have had intraocular lenses implanted after cataract surgery, are not covered under medical plans.  Contact lenses and eyeglasses may be covered under the member's vision care plan.

  3. Therapeutic Hydrophilic Contact Lenses (Corneal Bandage)

    Therapeutic soft (hydrophilic) contact lenses or gas-permeable fluid ventilated scleral lenses (e.g., Boston Scleral Lens) are considered medically necessary prosthetics under medical plans where used as moist corneal bandages for the treatment of severe ocular surface diseases, including

    1. Corneal stem cell deficiency (Stevens-Johnson syndrome/TEN, chemical and thermal injuries to the eye including surgical procedures, aniridia, idiopathic corneal stem cell deficiency and ocular pemphigoid); or
    2. Neurotrophic (anesthetic) corneas, such as may result from:

      1. Acquired etiologies, such as may result from acoustic neuroma surgery, trigeminal ganglionectomy, trigeminal rhyzotomy, herpes simplex/zoster of the cornea, diabetes; or
      2. Congenital etiologies, such as congenital corneal anesthesia (familial dysautonomia), Seckle's syndrome; or

    3. Severe dry eyes (keratoconjunctivitis sicca) (such as from Sjogren's syndrome, chronic graft versus host disease, radiation, surgery, meibomian gland deficiency); or
    4. Corneal disorders associated with systemic autoimmune diseases (rheumatoid arthritis, dermatological disorders such as atopic, epidermolysis bullosa, epidermal dysplasia); or
    5. Epidermal ocular disorders (atopy, ectodermal dysplasia, epidermolysis bullosa); or
    6. Corneal exposure (e.g., anatomic, paralytic). 

      Corneal bandages are considered experimental and investigational for all other indications.

      Note: Liquid bandage scleral lenses are covered under plans that exclude coverage of contact lenses, as these lenses are not primarily for correction of refractive errors.

      Note: For scleral lenses for masking irregular astigmatism, see section below. 

    Replacement lenses are considered medically necessary under medical plans if required because of a change in the patient's physical condition (not including refractive changes).  Note: Charges to replace contact lenses that are lost, damaged, or required solely due to refractive changes are not covered under medical plans.

  4. Scleral Shell Contact Lenses

    Scleral shell contact lenses are considered medically necessary under medical plans for the following indications:

    1. For the treatment of keratoconjunctivitis sicca or “dry eye"; or
    2. When prescribed to support orbital tissue (such as where an eye has been rendered sightless and shrunken by inflammatory disease).

    Replacement lenses are considered medically necessary under medical plans if required because of a change in the member's physical condition (not including refractive changes).  Note: Charges to replace contact lenses that are lost, damaged, or required solely due to refractive changes are not covered under medical plans.

    Note: Scleral shell lenses are covered under plans that exclude coverage of contact lenses, as scleral shell lenses are not primarily for correction of refractive errors.

  5. Contact Lenses and Eyeglasses for Accidental Injury

    An initial pair of contact lenses or eyeglasses is considered medically necessary under medical plans when they are prescribed by a physician to correct a change in vision directly resulting from an accidental bodily injury.  Note: Charges to replace such contact lenses or eyeglasses are not covered under medical plans.

  6. Contact Lenses for Masking Irregular Astigmatism Associated with Keratoconus and Other Corneal Disorders

    Aetna considers services that are part of an evaluation of keratoconus or other corneal disorders associated with irregular astigmatism (e.g., keratoglobus, pellucid corneal degeneration, Terrien's marginal degeneration, post-LASIK ectasia, corneal scarring) medically necessary.  This includes the general examination, advanced corneal topographic modeling, and fitting of contact lenses or scleral lenses.

    Note: Most Aetna medical benefit plans exclude coverage of contact lenses and other vision aids.  Please check benefit plan descriptions for details.  These benefit plans do not cover contact lenses or scleral lenses for correcting astigmatism associated with keratoconus or other corneal disorders under medical plans that exclude coverage of contact lenses and eyeglasses.  This includes corneal contact lenses and scleral lenses that may be prescribed for masking irregular astigmatism associated with corneal ectasia (e.g., keratoconus, keratoglobus, pellucid corneal degeneration, Terriens marginal degeneration, post-LASIK ectasia), post-operative astigmatism (e.g., following refractive surgery or corneal transplant), corneal scarring (e.g., from trauma, infection, or Hydrops), and anterior corneal dystrophies (e.g. Meesman's, Cogan's).  Contact lenses and scleral lenses provided to members with keratoconus and other corneal disorders associated with irregular astigmatism are covered under the provisions of the member's vision care plan only.

*Note: Some HMO plans cover only an initial prosthetic, and exclude coverage of replacements of prosthetics regardless of medical necessity.  Under these plans, only an initial set of glasses or contact lenses are covered under the medical plan.  Please check benefit plan descriptions for details.

See also CPB 0508 - Cataract Removal Surgery.



Background

Therapeutic soft hydrophilic contact lenses are made of poly-2-hydroxyethyl methacrylate and other flexible plastics. They are about 13 to 15 mm in diameter and cover the entire cornea. Hydrophilic contact lenses may be prescribed for the treatment of bullous keratopathy and other corneal disorders (bandage lenses). Prophylactic antibiotic eye-drops may be used with a bandage lens. Most therapeutic eye-drops can be used with hydrophilic lenses.

The Boston Scleral Lens is a fluid-ventilated scleral lens designed to enclose aqueous fluid over the corneal surface. The scleral lens acts as a corneal bandage, and can mask irregular astigmatism.  The scleral lens rests entirely on the sclera and avoids all contact with the cornea.  Thus, the scleral lens can be used by persons who are intolerant to standard (hard) contact lenses, which rest on the sensitive cornea. The Boston Scleral lens has a series of channels that aspirate tears into the fluid reservoir while preventing the formation of air bubbles in the reservoir.

Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. A scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens that covers only the central nonwhite area encompassing the pupil and iris.

When an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding tissue. In such a case, the device serves essentially as an artificial eye.

Scleral shells are occasionally used in connection with artificial tears in the treatment of “dry eye” of diverse etiology. Tears ordinarily dry at a rapid rate, and are continually replaced by the lacrimal gland. When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by the use of the scleral shell contact lens as a protective barrier against the drying action of the atmosphere. Thus, the difficult and sometimes hazardous process of frequent instillation of artificial tears may be avoided. The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal glands and would be considered a prosthetic device in the rare case when it is used in the treatment of dry eye.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Prosthetic Contact Lenses and Eyeglasses for Aphakia:
CPT codes covered if selection criteria are met:
92311
92312
92315
92316
92352 - 92353
92358
CPT codes not covered for indications listed in the CPB:
92326
92371
HCPCS codes covered if selection criteria are met:
S0592 Comprehensive contact lens evaluation
V2020 Frames, purchases
V2100 - V2499 Eyeglasses
V2500 - V2599 Contact lens
V2630 - V2632 Intraocular lenses
V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens
V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens
V2784 Lens, polycarbonate or equal, any index, per lens
HCPCS codes not covered for indications listed in the CPB:
S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens
S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0510 Non-prescription lens (safety, athletic, or sunglass), per lens
S0514 Color contact lens, per lens
S0516 Safety eyeglass frames
S0518 Sunglasses frames
S0580 Polycarbonate lens (list this code in addition to the basic code for the lens)
S0581 Nonstandard lens (list this code in addition to the basic code for the lens)
S0590 Integral lens service, miscellaneous services reported separately
S0595 Dispensing new spectacle lenses for patient supplied frame
V2025 Deluxe frame
V2702 Deluxe lens feature
V2744 Tint, photochromatic, per lens
V2745 Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens
V2750 Antireflective coating, per lens
V2756 Eye glass case
V2760 Scratch resistant coating, per lens
V2761 Mirror coating, any type, solid, gradient or equal, any lens material, per lens
V2762 Polarization, any lens material, per lens
V2780 Oversize lens, per lens
V2781 Progressive lens, per lens
V2786 Specialty occupational multifocal lens, per lens
ICD-9 codes covered if selection criteria are met:
366.00 - 366.9 Cataract
379.31 Aphakia
743.35 Congenital aphakia
V43.1 Organ or tissue transplant replaced by other means, eye lens
V45.61 Cataract extraction status
Other ICD-9 codes related to the CPB:
V53.09 Fitting and adjustment of other devices related to nervous system and special senses
V53.1 Fitting and adjustment of spectacles and contact lenses
V72.0 Examination of the eyes and vision
Therapeutic Hydrophilic Contact Lenses (Corneal Bandage):
CPT codes covered if selection criteria are met:
92071
92072
HCPCS codes covered if selection criteria are met:
S0515 Scleral lens, liquid bandage device, per lens
V2520 - V2523 Contact lens, hydrophilic
V2530 Contact lens, scleral, gas impermeable, per lens
V2531 Contact lens, scleral, gas permeable, per lens
ICD-9 codes covered if selection criteria are met:
279.52 Chronic graft-versus-host disease
370.33 Keratoconjunctivitis sicca, not specified as Sjogren's
370.34 Exposure keratoconjunctivitis
370.35 Neutrophic keratoconjunctivitis
371.81 Corneal anesthesia and hypoesthesia
375.15 Tear film insufficiency, unspecified
694.61 Benign mucous membrane pemphigoid, with ocular involvement
695.13 Stevens-Johnson syndrome
695.14 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome
695.15 Toxic epidermal necrolysis
710.2 Sicca syndrome
714.0 - 714.2 Rheumatoid arthritis
742.8 Other specified anomalies of nervous system [familial dysautonomia]
743.45 Aniridia
757.31 Congenital ectodermal dysplasia
757.39 Other specified anomalies of skin [epidermolysis bullosa]
759.89 Other specified congenital anomalies [Seckle's syndrome]
940.0 - 940.5 Burn confined to eye and adnexa
990 Effects of radiation, unspecified
Other ICD-9 codes related to the CPB:
053.12 Postherpetic trigeminal neuralgia
053.21 Herpes zoster keratoconjunctivitis
054.42 Dendritic keratitis
054.43 Herpes simplex disciform keratitis
225.1 Benign neoplasm of cranial nerves [acoustic neuroma]
250.50 - 250.53 Diabetes with ophthalmic manifestations
350.1 - 350.9 Trigeminal nerve disorders
351.0 - 351.9 Facial nerve disorders
V15.09 Other allergy, other than medicinal agents [atopy]
Scleral Shell Contact Lenses:
CPT codes covered if selection criteria are met:
92313
92317
HCPCS codes covered if selection criteria are met:
V2627 Scleral cover shell
ICD-9 codes covered if selection criteria are met:
370.33 Keratoconjunctivitis sicca, not specified as Sjogren's
375.15 Tear film insufficiency, unspecified
376.10 Chronic inflammation of orbit, unspecified
376.40 - 376.47 Deformity of orbit
710.2 Sicca syndrome [Sjogren's disease]
Contact Lenses and Eyeglasses for Accidental Injury:
CPT codes covered if selection criteria are met:
92310
92314
CPT codes not covered for indications listed in the CPB:
92326
ICD-9 codes covered if selection criteria are met:
360.50 - 360.69 Foreign Body, intraocular
870.0 - 871.9 Open wound of ocular adnexa and eyeball
906.0 Late effect of open wound of head, neck, and trunk
906.5 Late effect of burn of eye, face, head, and neck
918.0 - 918.9 Superficial injury of eye and adnexa
921.1 - 921.9 Contusion of eye and adnexa
930.0 - 930.9 Foreign body on external eye
V15.5 Personal history of injury
Contact Lenses for Masking Irregular Astigmatism Associated with Keratoconus and Other Corneal Disorders:
CPT codes covered if selection criteria are met:
92025
92071
92072
HCPCS codes covered if selection criteria are met:
S0592 Comprehensive contact lens evaluation
V2500 - V2599 Contact lens
ICD-9 codes covered if selection criteria are met:
371.00 - 371.05 Corneal scars and opacities
371.40 - 371.49 Corneal degenerations
371.60 - 371.62 Keratoconus
371.71 Corneal ectasia [post-LASIK]
743.22 Buphthalmos associated with other ocular anomalies [keratoglobus]
743.41 Anomalies of corneal size and shape
Other ICD-9 codes related to the CPB:
367.22 Irregular astigmatism


The above policy is based on the following references:
  1. Azem H. Contact lenses--an overview. Wien Med Wochenschr. 1997;147(12-13):293-294.
  2. Kora Y, Yaguchi S, Inatomi M, et al. Preferred postoperative refraction after cataract surgery for high myopia. J Cataract Refract Surg. 1995;21(1):35-38.
  3. Olsen T, Bargum R. Outcome monitoring in cataract surgery. Acta Ophthalmol Scand. 1995;73(5):433-437.
  4. Olsen T. Predicting the refractive result after cataract surgery. J Cataract Refract Surg. 1996;22(5):575-578.
  5. Holladay JT, Rubin ML. Avoiding refractive problems in cataract surgery. Surv Ophthalmol. 1988;32(5):357-360.
  6. Szczotka LB, Rabinowitz YS, Yang H. Influence of contact lens wear on the corneal topography of keratoconus. CLAO J. 1996;22(4):270-273.
  7. Edrington TB, Barr JT, Zadnik K, et al. Standardized rigid contact lens fitting protocol for keratoconus. Optom Vis Sci. 1996;73(6):369-375.
  8. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Scleral shell. Medicare Coverage Issues Manual §65-3. Baltimore, MD: HCFA; 1999.
  9. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Hydrophilic contact lenses. Medicare Coverage Issues Manual §65-1. Baltimore, MD: HCFA; 1999.
  10. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Hydrophilic contact lens for corneal bandage. Medicare Coverage Issues Manual §45-7. Baltimore, MD: HCFA; 1999.
  11. Beers MH, Berkow M, eds. Merck Manual of Diagnosis and Therapy. 17th ed. West Point, PA: Merck & Co.; 1999.
  12. Vaughan D, Asbury T, Riordan-Eva P, eds. General Ophthalmology. 15th ed. Stamford, CT: Appleton & Lange; 1999.
  13. Rosenthal P. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye Contact Lens. 2005;31(3):130-134.
  14. Schien OD, Rosenthal P, Ducharme C. A gas-permeable scleral contact lens for visual rehabilitation. Am J Ophthalmol. 1990;109(3):318-322.
  15. Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol. 2000;130(1):33-41.
  16. Watson SL, Barker NH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2007:(4):CD001861.
  17. Shepard DS, Razavi M, Stason WB, et al. Economic appraisal of the Boston Ocular Surface Prosthesis. Am J Ophthalmol. 2009;148(6):860-868.
  18. Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG, Drews-Botsch C, 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;128(7):810-818.
  19. NHIC, Corp. Local Coverage Determination (LCD) for Refractive Lenses (L11532). Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised January 1, 2011.
  20. NHIC, Corp. Local Coverage Article for Refractive Lenses - Policy Article - Effective January 2011 (A23658). Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdication A. Hingham, MA: NHIC; January 2011.
  21. State of California, Department of Healthcare Services (DHS). Eyeglass lenses. Part 2 - Vision Care. Medi-Cal Provider Manual. Sacramento, CA: DHS; April 2011.
  22. Goss DA, Grosvenor TP, Keller JT, et al.; American Optometric Association (AOA) Consensus Panel on Care of the Patient with Myopia. Care of the patient with myopia. Optometric Clinical Practice Guideline. St. Louis, MO: AOA; reviewed 2006.
  23. Moore BD, Augsburger AR, Ciner EB, et al. American Optometric Association (AOA) Consensus Panel on Care of the Patient with Hyperopia. Care of the patient with hyperopia. Optometric Clinical Practice Guideline. St. Louis, MO: AOA; revised 2008.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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