Eye Prostheses - Policy Article

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Added: “Prosthetic devices that are custom fabricated for the individual beneficiary are not solely restricted to standard methods of fabrication and can include alternative fabrication methods (e.g., additive manufacturing). Correct coding of custom fabricated items includes compliance with the HCPCS long description of the individual HCPCS code, along with any other published coding guidelines.” as clarification


09/18/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.” as clarification


04/03/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Removed: “Claims for eye prostheses from nonphysicians provided in an office or nursing home setting are submitted to the DME MAC. Claims for eye prostheses from physicians in these settings are submitted to the applicable A/B MAC.”
Added: “Physicians who are enrolled as a DMEPOS supplier are to submit claims for eye prostheses provided in an office or nursing home setting by nonphysicians or physicians to the DME MAC.”
MODIFIERS
Added: “MODIFIERS” section and right (RT) and/or left (LT) modifier information
CODING GUIDELINES
Removed: Right (RT) and/or left (LT) modifier information


03/21/2024: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Revised: “provides” to “provide”
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Removed: Trademark symbols from PROSE references, per AMA guidelines


03/25/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician’s” to “treating practitioner’s”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “physician’s” to “treating practitioner’s”
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019


CODING GUIDELINES:
Revised: RT and LT modifier billing instructions
Added: Coding guidelines for PROSE
®
 device


02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017


NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:


Added: Information regarding implanted components


04/05/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Reasonable Useful Lifetime verbiage
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: New reference language and directions to Standard Documentation Requirements
Added: Replacement instructions (previously in the related LCD)
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 07/01/2016
NON-MEDICAL NECESSITY COVERAGE & PAYMENT RULES:
Added: Instructions for services and items included in the allowance of the eye prostheses, and not separately billable

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.