TRANSMITTAL #: 135

DATE: 12/02/2013

TRICARE CHANGE #: N/A

CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 10.4

TITLE:  LENSES (INTRAOCULAR OR CONTACT) AND EYE GLASSES

AUTHORITY:  38 CFR 17.270(a) and 17.272(a)

RELATED AUTHORITY:  32 CFR 199.4(d)(3)(vii), (e)(6)(i) and (e)(6)(ii)

I. EFFECTIVE DATE(S)

January 23, 1984

II. PROCEDURE CODE(S)

A.      CPT Codes: 65125-65175, 92071-92072, and 92310-92326

B.      HCPCS Level II Codes: V2630-V2632

III. DESCRIPTION(S)

A.      There are two types of Intraocular Lenses (IOL's): anterior lenses, which are implanted into the anterior chamber of the eye in front of the iris, and posterior lenses, which are implanted into the posterior chamber of the eye behind the iris and resting against the capsular bag.

B.      There are two primary types of contact lenses, hydrophilic (water-loving) soft lenses, and rigid or hard type materials.  

C.      Soft lenses are made of plastics, which contain 36%-74% water. The diameter varies from 10.5 to 15.5 mm. Soft lenses are available in almost any optical correction, including myopia, hyperopia, astigmatism, and bifocal. Hard lenses are generally gas permeable materials and are called Rigid, Gas Permeable (RGP). RGP lenses have diameters between eight mm and ten mm and inside curves which match the curvature of the cornea. There are also a number of lenses which combine soft and RGP materials. Both lenses are available in many optical corrections.

D.      Eye surgery is defined as any surgical procedure involving the eyes, to include intraocular surgery and cataract surgery.

IV. POLICY

A.      A physician's prescription is required with all claims for covered lenses, both the initial lenses and any lenses required due to a change in the patient’s condition.   

B.      Lenses must be Food and Drug Administration (FDA) approved.

C.      Benefits are specifically limited to one set of lenses that includes both contact lenses and eyeglasses when a combination is necessary to restore vision.

D.      Benefits for eyeglasses, spectacles, contact lenses, or other optical devices are only covered in the following circumstances:

1.       When necessary to perform the function of a human lens lost as a result of eye surgery, ocular injury, or congenital absence.

2.       Pinhole glasses prescribed for use after surgery for detached retina.

3.       Lenses prescribed as "treatment" instead of surgery for the following conditions:

a.       Contact lenses used for treatment of infantile glaucoma.

b.       Corneal or scleral lenses prescribed with treatment of keratoconus.

c.        Scleral lenses prescribed to retain moisture when normal tearing is not present or is inadequate.

d.       Corneal or scleral lenses prescribed to reduce a corneal irregularity other than astigmatism.

e.       Intraocular lenses, contact lenses, or eyeglasses to perform the function of the human lens lost as the result eye surgery, or ocular injury, or congenital absence.

E.       When there is a prescription change still related to the qualifying eye condition, a new set of lenses may be covered for replacement lenses that are deteriorated or unusable due to physical growth subject to clinical review.

V. EXCLUSION(S)

A.      When the prescription remains unchanged, or lenses that are lost.

B.      Adjustments, cleaning or repair of lenses and glasses is not covered.

C.      Special features on eye glasses, such as tinting or transitional lenses, unless specifically prescribed by a physician as being medically necessary.

*END OF POLICY*