Eye Prosthesis
Number: 0619
Policy
Aetna considers eye prostheses medically necessary for members with an absence or shrinkage 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.
Note: Trial scleral cover shells are not separately payable. They are included in the allowance for scleral cover shells.
Background
This policy is based upon Medicare DME MAC policy.
Eye Prostheses Generated by Computer-Aided Design and Rapid Manufacturing
Alam and colleagues (2017) stated that ocular prosthesis is either a ready-made stock shell or custom made prosthesis (CMP). Presently, there is no other technology available, which is either superior or even comparable to the conventional CMP. In a pilot study, these researchers designed to fabricate ocular prosthesis using computer-aided design (CAD) and rapid manufacturing (RM) technology and compared it with CMP. The ocular prosthesis prepared by CAD was compared with conventional CMP in terms of time taken for fabrication, weight, cosmesis, comfort, and motility; 2 eyes of 2 patients were included. Computerized tomography scan of wax model of socket was converted into 3-D format using the Materialize Interactive Medical Image Control System (MIMICS) software and further refined. This was given as an input to rapid manufacturing machine (Polyjet 3-D printer). The final painting on prototype was done by an ocularist. The average effective time needed for fabrication of CAD prosthesis was 2.5 hours; and weighed 2.9 g. The same for CMP were 10 hours; and 4.4 g; CAD prosthesis was more comfortable for both the patients. The authors concluded that the findings of this study demonstrated the first ever attempt of fabricating a complete ocular prosthesis using CAD and rapid manufacturing and comparing it with conventional CMP. They reported that this prosthesis took lesser time for fabrication, and was more comfortable. They stated that studies with larger sample size are needed to further validate this technique.
| Code | Code Description |
|---|---|
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 ophthalmological 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 |
HCPCS codes not covered for indications listed in the CPB: |
|
| V2627 | Scleral cover shells [trial scleral cover shells are not separately payable] |
ICD-10 codes covered if selection criteria are met: |
|
| Q11.1 | Other anophthalmos [congenital absence of eye] |
| S05.00x+ - S05.92x+ | Injury of eye and orbit |
| Z90.01 | Acquired absence of eye |
The above policy is based on the following references:
- Alam S, Sugavaneswaran M, Arumaikkannu G, Mukherjee B. An innovative method of ocular prosthesis fabrication by bio-CAD and rapid 3-D printing technology: A pilot study. Orbit. 2017;36(4):223-227.
- Chin K, Margolin CB, Finger PT. Early ocular prosthesis insertion improves quality of life after enucleation. Optometry. 2006;77(2):71-75.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
