VERZIHEALTHGet a key
Coverage Knowledge Base

Every policy word on this page is CMS's own. Verzi adds pins, receipts, and links only.

Refractive Lenses - Policy Article

Article A52499 · 9 versions, 2015 to today · last changed 2020-10-01 (R8)

Version 23 of Article A52499: in force by CMS's dates 2020-10-01 onward. The policy text on this page comes from this archived version.

DME MAC jurisdictions
JA · Noridian 16013
CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT
JB · CGS 17013
IL, IN, KY, MI, MN, OH, WI
JC · CGS 18003
AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, WV
JD · Noridian 19003
AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, NE, NV, ND, MP, OR, SD, UT, WA, WY
source

CMS's Who are the MACs jurisdiction pages (DME facts as of 2025-09-30) name each contractor and its states; the MCD's Contractor Information table on every DME LCD prints the contract numbers. Both read 2026-10-09. Verzi adds the state lookup only.

CMS's newest revision note (R8, 2020-10-01), quoted

Revision Effective Date: 10/01/2020 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised: "Prosthetics and Artificial Limbs" to "prosthetic devices" CONTINUED MEDICAL NEED: Added: Section header and continued medical need language 05/26/2022: 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.
source

This quote comes from CMS's revision-history file, not from the version's own file: Our archived file.

Sections in this version: Article Text. Plus 4 sections marked N/A in this version.

ICD-10-CM Codes that Support Medical Necessity (6 codes)

Group 1: 6 codes

CMS published no paragraph for this group.

ICD-10-CM Codes that DO NOT Support Medical Necessity (CMS lists no codes)

Group 1: CMS lists no codes in this group

CMS published no paragraph for this group.

CMS's list for version 23. The full code table serves customers with an API key.

source

CMS's ICD-10-CM lists in the Medicare Coverage Database download, archived 2026-10-09: Our archived file.

Full verbatim text serves to customers · Customer? Log in

Version history, Article A52499

CMS numbers each version. Each box shows the version's window by CMS's stated dates. Select a version to show it on this page. Versions superseded the same day they took effect never governed a claim, so the page hides them until you ask. Version numbers CMS never published to its archive do not exist as documents.

Revision history, every version

CMS's own change log, quoted, 8 entries. It does not change with the version shown. A revision (R-number) is a change CMS logged. The version (vN) is the snapshot that carries it.

R8 · 2020-10-01 · v23
Revision Effective Date: 10/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: "Prosthetics and Artificial Limbs" to "prosthetic devices"
CONTINUED MEDICAL NEED:
Added: Section header and continued medical need language

05/26/2022: 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.
R7 · 2020-10-01 · v19
Revision Effective Date: 10/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
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 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.
R6 · 2020-10-01 · v16
Revision Effective Date: 10/01/2020
CODING GUIDELINES:
Added: Guideline information for HCPCS code V2524


10/15/2020: 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.
R5 · 2020-01-01 · v14
Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
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
MODIFIERS:
Revised: “physician” to “practitioner”
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
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”

02/13/2020: 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.
R4 · 2019-03-01 · v11
Revision Effective Date: 03/01/2019
CODING GUIDELINES:
Revised: RT and LT modifier billing instructions
Added: Coding guidelines for PROSE
®
devices


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.
R3 · 2017-01-01 · v8
Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Diagnosis requirement on a claim and Modifier instructions
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
R2 · 2016-07-01 · v6
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.
R1 · 2015-10-01 · v4
Revision Effective Date: 10/01/2015 (February 2015 Publication)
Removed: Reference to ICD-9 located in the narrative
Receipts for auditors

Version 23 of Article A52499, shown on this page: in force by CMS's dates 2020-10-01 onward. Archived 2026-09-26. CMS's copy · Our archived file. 5 of 5 sections are proven word-identical to the archived file.

Every archived version of Article A52499 (9 versions, CMS's dates, window by the as-of rule).

DocumentVersionIn forceArchived onVerify
Article A52499version 22015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
Article A52499version 42015-10-01 to 2016-06-302026-09-26CMS's copy · Our archived file
Article A52499version 62016-07-01 to 2016-12-312026-09-26CMS's copy · Our archived file
Article A52499version 82017-01-01 to 2019-02-282026-09-26CMS's copy · Our archived file
Article A52499version 112019-03-01 to 2019-12-312026-09-26CMS's copy · Our archived file
Article A52499version 142020-01-01 to 2020-09-302026-09-26CMS's copy · Our archived file
Article A52499version 162020-10-01, superseded same day2026-10-09CMS's copy · Our archived file
Article A52499version 192020-10-01, superseded same day2026-10-09CMS's copy · Our archived file
Article A52499version 23 shown2020-10-01 to today2026-09-26CMS's copy · Our archived file

Each archived file's page gives its sha256 fingerprint. A copy of the file hashes to the same value, byte for byte.

CMS's live page shows only the current version. To check a passage by eye, open CMS's copy of the same version number. A version's window ends on the earlier of CMS's stated end date and the day before the next version starts.

Every policy word on this page is CMS's, from the archived version named beside it. Verzi adds labels, highlights, citations and links only. Verzi-written summary content on this page: none.