92326
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$39.08
Non-Facility
$39.08
Documentation Required
- For myopia management lenses (MiSight 1 Day), documentation of patient age at initiation (8–12 years), refraction (-0.75 to -4.00 D spherical equivalent) and astigmatism ≤ 0.75 D, and that lenses are prescribed/managed by a qualified eye care professional.
- For Acuvue Abiliti Overnight, documentation of refractive error (≤ -4.00 D) and astigmatism (≤ 1.50 D), corneal topography/fitting records and that fitting was performed per manufacturer/clinical guidelines.
- When requesting replacements after cataract surgery for Medicare members, documentation consistent with CMS requirements for consideration of replacement of lost or broken contact lenses or eyeglasses.
- Medical record documentation of the diagnosis (e.g., aphakia, cataract extraction status, corneal disease ICD-10 codes) to support medical necessity.
Key Coverage Criteria
- Lenses made of polycarbonate or other impact-resistant materials (e.g., Trivex) for members with functional vision in only one eye.
- Replacement eyeglasses under plans with a pediatric vision benefit when one or more of the following are met: (a) there is a change in refractive error; (b) with regular use the previous eyeglasses were broken or marred to a degree significantly interfering with vision or eye safety; (c) eyeglasses are replaced because a different frame size or shape is necessary due to the child's growth, metal allergy or other justifiable medical reasons.
- Prosthetic external lenses (contacts or spectacles) and intraocular lenses medically necessary after cataract surgery to replace the crystalline lens (aphakia), including post-surgical external lenses customarily used during convalescence from cataract removal surgery.
- Intraocular lenses as a medically necessary prosthesis for individuals lacking an organic lens because of surgical removal (e.g., cataract surgery) or congenital absence (congenital aphakia).
- Bifocal spectacles, or spectacles for far vision or for near vision, when used to essentially restore vision provided by the crystalline lens after cataract surgery (aphakia).
- Contact lenses for far vision (including binocular and monocular aphakia), including both contact lens(es) and spectacles for near vision that are worn simultaneously with the contact lenses or when the contact lenses have been removed (aphakia).
3 Active Policies
AMBETTER-CP.VP.06 — Medically Necessary Optical Hardware
AMBETTER-CP.VP.13-Attachment-A-Refractive-Hardware — Preventive (Routine) Eye Examination Attachment A: Refractive Hardware
AETNA-CPB-0126 — Contact Lenses and Eyeglasses
Related Codes
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