V2511 — Contact lens, gas permeable, toric, prism ballast, per lens
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be received by the supplier before claim submission; for DMEPOS base items requiring a WOPD, a signed SWO/WOPD must be received before delivery.
- Treating practitioner must document medical necessity for anti-reflective coating (V2750), tints (V2744, V2745), oversize lenses (V2780), and other special features when coverage is claimed.
- Suppliers must maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.
- Claims must follow CMS HCPCS coding guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; consult the LCD-related Standard Documentation Requirements Article and Supplier Manual for additional documentation rules.
Key Coverage Criteria
- An item is covered only if it: 1) is eligible for a defined Medicare benefit category, 2) is reasonable and necessary for diagnosis/treatment or to improve functioning of a malformed body member, and 3) meets all other applicable Medicare statutory and regulatory requirements (SSAct §1862(a)(1)(A)).
- For aphakic beneficiaries, bifocal lenses in frames, or lenses in frames for far vision plus lenses in frames for near vision, or contact lens(es) for far vision together with near-vision lenses in frames (and frames to be used when contacts are removed) are covered when determined medically necessary.
- Initial pair of lenses for pseudophakic beneficiaries may be covered as specified in the related LCD Policy Article (see Policy Article for criteria).
- Replacement lenses for aphakic beneficiaries are covered when medically necessary.
- Anti-reflective coating (V2750), tints (V2744, V2745), and oversize lenses (V2780) are covered only when the treating practitioner documents they are medically necessary for the individual beneficiary.
- UV protection/coating is reasonable and necessary following cataract extraction (no additional justification beyond inclusion on the order is required), except UV coating (V2755) is not reasonable for polycarbonate lenses (V2784).
3 Active Policies
L33793 — Refractive Lenses
J19
AMBETTER-CP.VP.06 — Medically Necessary Optical Hardware
AMBETTER-CP.VP.13-Attachment-A-Refractive-Hardware — Preventive (Routine) Eye Examination Attachment A: Refractive Hardware
Related Codes
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