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 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|