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.Background
This policy is based upon Medicare DMERC policy.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|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-9 codes covered if selection criteria are met:|
|743.00||Anophthalmos, congenital absence of eye|
|V45.78||Acquired absence of eye|