V2623, Prosthetic eye, plastic, custom
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 communicated to the supplier before a claim is submitted for items addressed in this policy.
- For DMEPOS base items that require a WOPD, the supplier must have received a signed SWO/WOPD before delivering the DMEPOS item to the beneficiary.
- For DMEPOS base items with separately billed associated options/accessories/supplies, the WOPD must list the base item and may list associated separately billed items prior to delivery.
- Medical record documentation must support medical necessity for additional enlargements/reductions beyond the one covered and must be available upon request.
Key Coverage Criteria
- Eye prosthesis is covered for a beneficiary with absence (anophthalmia) or shrinkage (phthisis) of an eye due to birth defect, trauma, or surgical removal (enucleation/evisceration).
- Polishing and resurfacing of an ocular prosthesis (HCPCS V2624) is covered up to twice per calendar year.
- One enlargement (HCPCS V2625) or one reduction (HCPCS V2626) of an ocular prosthesis is covered without additional documentation.
- Covered items must be within a defined Medicare benefit category and be reasonable and necessary for diagnosis/treatment or to improve functioning of a malformed body member per Social Security Act §1862(a)(1)(A).
- Facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.
- Any item is covered only if it is in a defined Medicare benefit category and is reasonable and necessary for diagnosis or treatment of illness or injury or to improve functioning of a malformed body member.
6 Active Policies
HUMANA-PROSTHETICS-OK-MEDICAID, Prosthetics
HUMANA-PROSTHETICS-KY-MEDICAID, Prosthetics
L33737, Eye Prostheses
L33738, Facial Prostheses
AETNA-CPB-0619, Eye Prosthesis
Related Codes
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