92071
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.59
Facility
$26.05
Non-Facility
$35.74
Documentation Required
- Eye Prostheses Refractive Lenses: 'Standard Documentation Requirements for All Claims Submitted to DME MACs' (exact title listed; specific required documents not provided in this excerpt).
- Amniotic membrane billing guidance referenced: 'Billing and Coding: Amniotic Membrane Billing Guidelines for HCPCS Code V2790' (title implies specific billing/documentation rules for V2790, but the detailed requirements are not included here).
- No specific clinical records, test results, or required clinical notes are included in this excerpt — the table only references documents that contain documentation requirements.
- Documentation of clinical diagnosis of ocular surface disease / dry eye disease (signs, symptoms, and diagnosis).
Key Coverage Criteria
- 92499 Unlisted ophthalmological service or procedure
- Treatment of moderate to severe dry eye in Sjogren's syndrome
- Ophthalmologic evaluation, including one or more of the following tests: Schirmer test (tear test) (83861)
- DED/OSD due to increased tear evaporation (for example, meibomian gland dysfunction).
- Symptomatic OSD causing eye discomfort (burning, dry eye, foreign body sensation, photophobia, tearing), visual disturbances, or potential damage to the ocular surface.
- Procedural and advanced therapies for OSD/DED when first-line treatments have proven unsuccessful.
2 Active Policies
AMBETTER-CP.VP.06 — Medically Necessary Optical Hardware
HUMANA-OCULAR-SURFACE-DISEASE-DIAGNOSIS-AND-TREATMENTS-MA — Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage
Related Codes
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