Refractive Lenses - Policy Article

Medicare covers refractive lenses under the prosthetic devices benefit only for beneficiaries lacking the natural lens due to surgical removal or congenital absence (aphakia, pseudophakia, congenital aphakia), including when surgery occurred before Medicare entitlement. Coverage for pseudophakic beneficiaries is limited to one pair of eyeglasses or contact lenses after each cataract extraction with IOL insertion; many lens add-ons, deluxe features, accessories, and replacements are noncovered unless specific medical necessity documentation and required modifiers (e.g., KX) are present and Final Rule 1713 face-to-face and WOPD requirements are met.

"Refractive lenses are covered when used to restore vision normally provided by the natural lens in individuals who lack the organic lens because of surgical removal or congenital absence."

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