Coverage Indications, Limitations, and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Eye prostheses are covered for a beneficiary with absence or shrinkage of an eye due to birth defect, trauma or surgical removal.
Polishing and resurfacing (V2624) is covered on a twice per year basis.
One enlargement (V2625) or reduction (V2626) of the prosthesis is covered without documentation. Additional enlargements or reductions are rarely medically necessary and are therefore covered only when there is information in the medical record which supports medical necessity. This information must be available upon request.
If an item or service does not meet the criteria specified in this section, it will be denied as not reasonable and necessary unless there is documentation in the medical record clearly explaining the medical necessity in the individual situation.
GENERAL
A Detailed Written Order (DWO) (if applicable) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed DWO, the claim shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
CPT/HCPCS Codes
Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS:
EY - No physician or other licensed health care provider order for this item or service
LT - Left side
RT - Right side
HCPCS CODES:
Group 1 Codes:
CODE DESCRIPTION
L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE
V2623 PROSTHETIC EYE, PLASTIC, CUSTOM
V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS
V2625 ENLARGEMENT OF OCULAR PROSTHESIS
V2626 REDUCTION OF OCULAR PROSTHESIS
V2627 SCLERAL COVER SHELL
V2628 FABRICATION AND FITTING OF OCULAR CONFORMER
V2629 PROSTHETIC EYE, OTHER TYPE
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
- The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
- The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
- Refer to the Supplier Manual for additional information on documentation requirements.
- Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Eye prostheses are covered for a beneficiary with absence or shrinkage of an eye due to birth defect, trauma or surgical removal.
Polishing and resurfacing (V2624) is covered on a twice per year basis.
One enlargement (V2625) or reduction (V2626) of the prosthesis is covered without documentation. Additional enlargements or reductions are rarely medically necessary and are therefore covered only when there is information in the medical record which supports medical necessity. This information must be available upon request.
If an item or service does not meet the criteria specified in this section, it will be denied as not reasonable and necessary unless there is documentation in the medical record clearly explaining the medical necessity in the individual situation.
GENERAL
A Detailed Written Order (DWO) (if applicable) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed DWO, the claim shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
CPT/HCPCS Codes
Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS:
EY - No physician or other licensed health care provider order for this item or service
LT - Left side
RT - Right side
HCPCS CODES:
Group 1 Codes:
CODE DESCRIPTION
L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE
V2623 PROSTHETIC EYE, PLASTIC, CUSTOM
V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS
V2625 ENLARGEMENT OF OCULAR PROSTHESIS
V2626 REDUCTION OF OCULAR PROSTHESIS
V2627 SCLERAL COVER SHELL
V2628 FABRICATION AND FITTING OF OCULAR CONFORMER
V2629 PROSTHETIC EYE, OTHER TYPE
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