92002
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.88
Facility
$37.74
Non-Facility
$84.84
Documentation Required
- Documentation supporting the medical necessity of more frequent replacement than every 5 years (text: 'unless documentation supports the medical necessity of more frequent replacement').
- Medical records documenting the absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect (text: 'medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect').
- Documentation of polishing/resurfacing services and frequency to support twice-yearly polishing/resurfacing when billed (text: 'twice-yearly polishing and re-surfacing of eye prosthesis medically necessary').
- Clinical justification when billing for enlargements or reductions beyond the one medically necessary alteration (text: 'Additional enlargements or reductions are rarely medically necessary').
Key Coverage Criteria
- Aetna considers eye prostheses medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect.
- Twice-yearly polishing and re-surfacing of eye prosthesis is medically necessary.
- Replacement of an eye prosthesis is medically necessary every 5 years unless documentation supports the medical necessity of more frequent replacement.
- One enlargement or reduction of the prosthesis is medically necessary; additional enlargements or reductions are rarely medically necessary.
- CPT codes 92002 - 92014 (General ophthalmological services) are covered if selection criteria are met.
- 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).
2 Active Policies
AMBETTER-CP.VP.13 — Preventative (Routine) Eye Examination
AETNA-CPB-0619 — Eye Prosthesis
Related Codes
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