Eye Prostheses

Medicare covers ocular prostheses for beneficiaries with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal, provided the item is within a Medicare benefit category and is reasonable and necessary per SSA §1862(a)(1)(A). Polishing/resurfacing (V2624) is allowed up to twice yearly; one enlargement (V2625) or reduction (V2626) is covered without documentation while additional changes require medical-record-supported necessity. Claims must have required documentation (SWO/WOPD, POD), comply with HCPCS coding and LCD-related documentation rules, and failure to meet these requirements will result in denial unless individualized medical necessity is documented.

"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)."