Eye Prosthesis

Number: 0619

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses eye prosthesis.

1. Medical Necessity

   1. Aetna considers eye prostheses medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect.
   2. Aetna considers twice-yearly polishing and re-surfacing of eye prosthesis medically necessary.
   3. Aetna considers replacement of an eye prosthesis medically necessary every 5 years unless documentation supports the medical necessity of more frequent replacement.
   4. Aetna considers one enlargement or reduction of the prosthesis medically necessary.  Additional enlargements or reductions are rarely medically necessary.

2. Policy Limitations and Exclusions

   Note: Trial scleral cover shells are not separately payable. They are included in the allowance for scleral cover shells.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
92002 - 92014	General ophthalmological services
HCPCS codes covered if selection criteria are met:
V2623	Prosthetic eye, plastic, custom
V2624	Polishing/resurfacing of ocular prosthesis
V2625	Enlargement of ocular prosthesis
V2626	Reduction of ocular prosthesis
V2628	Fabrication and fitting of ocular conformer
V2629	Prosthetic eye, other type
HCPCS codes not covered for indications listed in the CPB:
V2627	Scleral cover shells [trial scleral cover shells are not separately payable]
ICD-10 codes covered if selection criteria are met:
Q11.1	Other anophthalmos [congenital absence of eye]
S05.00x+ - S05.92x+	Injury of eye and orbit
Z90.01	Acquired absence of eye

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Background

This policy is based upon Medicare DME MAC policy.

Eye Prostheses Generated by Computer-Aided Design and Rapid Manufacturing

Alam and colleagues (2017) stated that ocular prosthesis is either a ready-made stock shell or custom made prosthesis (CMP).  Presently, there is no other technology available, which is either superior or even comparable to the conventional CMP.  In a pilot study, these researchers designed to fabricate ocular prosthesis using computer-aided design (CAD) and rapid manufacturing (RM) technology and compared it with CMP.  The ocular prosthesis prepared by CAD was compared with conventional CMP in terms of time taken for fabrication, weight, cosmesis, comfort, and motility; 2 eyes of 2 patients were included.  Computerized tomography scan of wax model of socket was converted into 3-D format using the Materialize Interactive Medical Image Control System (MIMICS) software and further refined.  This was given as an input to rapid manufacturing machine (Polyjet 3-D printer).  The final painting on prototype was done by an ocularist.  The average effective time needed for fabrication of CAD prosthesis was 2.5 hours; and weighed 2.9 g.  The same for CMP were 10 hours; and 4.4 g; CAD prosthesis was more comfortable for both the patients.  The authors concluded that the findings of this study demonstrated the first ever attempt of fabricating a complete ocular prosthesis using CAD and rapid manufacturing and comparing it with conventional CMP.  They reported that this prosthesis took lesser time for fabrication, and was more comfortable.  They stated that studies with larger sample size are needed to further validate this technique.

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References