V2626 — Reduction of ocular prosthesis
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).
- 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.
2 Active Policies
L33737 — Eye Prostheses
J19
AETNA-CPB-0619 — Eye Prosthesis
Related Codes
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