Intraocular Lens

Policy ID: O-4-019

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: December 14, 2021

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

An intraocular lens is a hard type of artificial lens which is surgically implanted in the eye to replace the natural crystalline lens.

Policy Application

For Date of Processing (DOP): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Pseudophakos Intraocular Lens

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The intraocular lenses listed below are covered prosthetic devices and are processed under the applicable procedure codes, subject to benefit coverage:

Iris fixation lenses
Irido-capsular fixation lenses
Posterior chamber lenses
Anterior chamber angle fixation lenses

Procedure Codes

L8699

V2630

V2631

V2632

Intraocular Lenses

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The intraocular lenses listed below are not covered prosthetic devices, as their purpose is to avoid the need for glasses following cataract surgery. Corrective lenses provided solely for refractive error or to compensate for the imperfect curvature of the cornea (astigmatism) are not a standard benefit and are excluded from coverage.

Presbyopia-correcting intraocular lens (e.g., CrystaLens, RESTOR, ReZoom)
Astigmatism-correcting intraocular lens and Clear lens extraction intraocular lens

Procedure Codes

V2787

V2788

Q1004

Q1005

Presbyopia or Astigmatism-Correcting Intraocular Lens

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

If a member chooses to have a presbyopia or astigmatism-correcting intraocular lens following cataract surgery, the lens itself will be denied as non-covered.

Any additional pre-, and intra post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL will also be denied as non-covered.

Procedure Codes

66982

66983

66984

Phakic Intraocular Lenses

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Phakic intraocular lenses are not covered prosthetic devices, as their purpose is to avoid the need for glasses. They are not a standard benefit and are excluded from coverage.

Procedure Code

S0596

Ocular Telescopic Prosthesis

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Ocular Telescopic Prosthesis including removal of Crystalline Lens is considered experimental/investigational.

Procedure Code

0308T

Intraocular (telescopic) Lens

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Intraocular (telescopic) Lens are not covered prosthetic devices. They are not a standard benefit and are considered experimental/investigational.

Procedure Code

C1840

Clear Lens Extraction Intraocular Lens

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Clear lens extraction intraocular lens is not a covered prosthetic device, as the purpose is to avoid the need for glasses. They are not a standard benefit and are not covered.

Procedure Codes

V2630

V2631

V2632

V2787

V2788

Presbyopia and Astigmatism-correcting IOLs

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Presbyopia and astigmatism-correcting IOLs are non-covered and will be denied.

Procedure Codes

V2787

V2788

Additional Pre- and Post-operative Services

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Any additional pre- and post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL will also be denied as non-covered.

Procedure Codes

V2630

V2631

V2632

V2787

V2788

Presbyopia-correcting or Astigmatism-correcting Intraocular Lens

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

When the presbyopia-correcting or astigmatism-correcting intraocular lens is inserted solely for the correction of refractive errors or to compensate for the imperfect curvature of the cornea (i.e., not for cataract surgery), the lens, the surgical procedure, and all pre- and post-operative care will deny as non-covered and will entirely be the member's financial responsibility.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Annual Review-no changes

Internal Medical Policy Committee 3-17-2021 Coding update-

Added procedure code C1840

Internal Medical Policy Committee 11-23-2021 Coding update-

Removed procedure code 0514T

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-19-2024 Annual Review - no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-4-018

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: March 02, 2021

Revision Effective Date: May 03, 2021

Last Reviewed: March 17, 2021

Archived Date: May 05, 2024

Applies To: Commercial and Medicaid Expansion

Description

An intraocular lens is a hard type of artificial lens which is surgically implanted in the eye to replace the natural crystalline lens.

Criteria

Pseudophakos Intraocular Lens

The intraocular lenses listed below are covered prosthetic devices and are processed under the applicable procedure codes, subject to benefit coverage:

Iris fixation lenses
Irido-capsular fixation lenses
Posterior chamber lenses
Anterior chamber angle fixation lenses

Procedure Codes

L8699

V2630

V2631

V2632

If a member chooses to have a presbyopia or astigmatism-correcting intraocular lens following cataract surgery, the lens itself will be denied as non-covered.

Presbyopia-correcting intraocular lens (e.g., CrystaLens, RESTOR, ReZoom)
Astigmatism-correcting intraocular lens and Clear lens extraction intraocular lens

Procedure Codes

V2787

V2788

Q1004

Q1005

Any additional pre-, and intra post-operative services beyond those typically provided in conjunction with a cataract extraction with insertion of a standard IOL will also be denied as non-covered.

Procedure Codes

0514T

Phakic intraocular lenses are not covered prosthetic devices, as their purpose is to avoid the need for glasses. They are not a standard benefit and are excluded from coverage.

Procedure Codes

S0596

Ocular Telescopic Prosthesis including removal of Crystalline Lens is considered experimental/investigational.

Procedure Codes

0308T

Intraocular (telescopic) Lens are not covered prosthetic devices. They are not a standard benefit and are considered experimental/investigational.

Procedure Codes

C1840

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Annual Review-no changes

Internal Medical Policy Committee 3-17-2021 Coding update-Added C1840

Medical Policies Quick Search

Intraocular Lens

Description

Policy Application

Criteria

Pseudophakos Intraocular Lens

Policy Application

Intraocular Lenses

Policy Application

Presbyopia or Astigmatism-Correcting Intraocular Lens

Policy Application

Phakic Intraocular Lenses

Policy Application

Ocular Telescopic Prosthesis

Policy Application

Intraocular (telescopic) Lens

Policy Application

Procedure Code

Clear Lens Extraction Intraocular Lens

Policy Application

Presbyopia and Astigmatism-correcting IOLs

Policy Application

Procedure Codes

Additional Pre- and Post-operative Services

Policy Application

Procedure Codes

Presbyopia-correcting or Astigmatism-correcting Intraocular Lens

Policy Application

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer