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Clinical Policy Bulletin:
Eye Prosthesis
Number: 0619


Policy

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


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 July 1, 2007.
  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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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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