Eye Prosthesis

Number: 0619


Aetna considers eye prostheses medically necessary for members with an absence of an eye due to trauma, surgical removal, or congenital defect.

Aetna considers twice-yearly polishing and re-surfacing of eye prosthesis medically necessary.

Aetna considers replacement of an eye prosthesis medically necessary every 5 years unless documentation supports the medical necessity of more frequent replacement.

Aetna considers one enlargement or reduction of the prosthesis medically necessary.  Additional enlargements or reductions are rarely medically necessary.


This policy is based upon Medicare DME MAC policy.


CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
92002 - 92014 General ophtalmological services
HCPCS codes covered if selection criteria are met:
V2623 Prosthetic eye, plastic, custom
V2624 Polishing/resurfacing of ocular prosthesis
V2625 Enlargement of ocular prosthesis
V2626 Reduction of ocular prosthesis
V2628 Fabrication and fitting of ocular conformer
V2629 Prosthetic eye, other type
ICD-10 codes covered if selection criteria are met:
Q11.1 Other anophthalmos [congenital absence of eye]
Z90.01 Acquired absence of eye
ICD-10 codes will become effective as of October 1, 2015

The above policy is based on the following references:
    1. NHIC, Corp. Eye prosthesis. Local Coverage Determination L11529. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA; NHIC; revised October 31, 2014.
    2. NHIC, Corp. Eye prosthesis. Local Coverage Article A33613. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised April 1, 2013.
    3. Vincent AL, Webb MC, Gallie BL, et al. Prosthetic conformers: A step towards improved rehabilitation of enucleated children. Clin Experiment Ophthalmol. 2002;30(1):58-59.
    4. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: A report by the American Academy of Ophthalmology. Ophthalmology. 2003;110(10):2054-2061.
    5. Chin K, Margolin CB, Finger PT. Early ocular prosthesis insertion improves quality of life after enucleation. Optometry. 2006;77(2):71-75.
    6. Song JS, Oh J, Baek SH. A survey of satisfaction in anophthalmic patients wearing ocular prosthesis. Graefes Arch Clin Exp Ophthalmol. 2006;244(3):330-335.
    7. Mattos BS, Montagna MC, Fernandes Cda S, Saboia AC. The pediatric patient at a maxillofacial service: Eye prosthesis. Braz Oral Res. 2006;20(3):247-251. 

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