Preventive (Routine) Eye Examination Attachment A: Refractive Hardware

This policy covers refractive hardware associated with preventive (routine) eye examinations, including fitting and dispensing of spectacles (frame and two lenses), applicable lens add-ons when allowed, and contact lens coverage as determined by the member's plan, for patients with refractive conditions such as myopia, hypermetropia, regular/irregular astigmatism, anisometropia/aniseikonia, presbyopia, accommodation disorders, amblyopia (deprivation/refractive/strabismic), strabismus, and encounters for abnormal eye findings or fittings/adjustments. Major limitations/requirements: coverage, frequency, and lens add-ons depend on the member’s specific reference plan; refractive hardware excludes medically necessary hardware (see CP.VP.06); listed codes do not guarantee coverage; only one frame code and one code per complete set may be billed, frames supplied by the member are not billable, and RT/LT modifiers must be used to indicate lens laterality.

"Coverage and frequency of frames and lenses are determined by the member's plan specifics and apply as stated in the member's plan."