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Eye Prosthesis - Medical Clinical Policy Bulletins AetnaPage 1 of 5Eye ProsthesisNumber: 0619POLICY*Please see amendment for Pennsylvania Medicaid at the end of this CPB.Aetna considers eye prostheses medically necessary for members withan absence or shrinkage of an eye due to trauma, surgical removal, orcongenital defect.Aetna considers twice-yearly polishing and re-surfacing of eye prosthesismedically necessary.Aetna considers replacement of an eye prosthesis medically necessaryPOLICY HISTORYLast Review: 08/25/2021Effective: 06/18/2002Next Review: 07/14/2022Review HistoryDefinitionsevery 5 years unless documentation supports the medical necessity ofmore frequent replacement.Clinical Policy BulletinNotesAetna considers one enlargement or reduction of the prosthesis medicallynecessary. Additional enlargements or reductions are rarely medicallynecessary.Note: Trial scleral cover shells are not separately payable. They areincluded in the allowance for scleral cover shells.BACKGROUNDThis policy is based upon Medicare DME MAC policy.Eye Prostheses Generated by Computer‐Aided Design and RapidManufacturingAlam and colleagues (2017) stated that ocular prosthesis is either aready-made stock shell or custom made prosthesis (CMP). Presently,there is no other technology available, which is either superior or evencomparable to the conventional CMP. In a pilot study, theseresearchers designed to fabricate ocular prosthesis using computeraided design (CAD) and rapid manufacturing (RM) technology andcompared it with CMP. The ocular prosthesis prepared by CAD wascompared with conventional CMP in terms of time taken for fabrication,weight, cosmesis, comfort, and motility; 2 eyes of 2 patients wereincluded.
Eye Prosthesis - Medical Clinical Policy Bulletins AetnaComputerized tomography scan of wax model of socket was convertedinto 3-D format using the Materialize Interactive Medical Image ControlSystem (MIMICS) software and further refined. This was given as aninput to rapid manufacturing machine (Polyjet 3-D printer). The finalpainting on prototype was done by an ocularist. The average effectivetime needed for fabrication of CAD prosthesis was 2.5 hours; andweighed 2.9 g. The same for CMP were 10 hours; and 4.4 g; CADprosthesis was more comfortable for both the patients. The authorsconcluded that the findings of this study demonstrated the first everattempt of fabricating a complete ocular prosthesis using CAD and rapidmanufacturing and comparing it with conventional CMP. They reportedthat this prosthesis took lesser time for fabrication, and was morecomfortable. They stated that studies with larger sample size are neededto further validate this technique.CPT Codes/ HCPCS Codes/ICD-10 CodesInformation in the [brackets] below has been added for clarificationpurposes. Codes requiring a 7th character are represented by “ ”CodeCode Description92002 -General ophthalmological services92014HCPCS codes covered if selection criteria are met:CodeCode DescriptionV2623Prosthetic eye, plastic, customV2624Polishing/resurfacing of ocular prosthesisV2625Enlargement of ocular prosthesisV2626Reduction of ocular prosthesisV2628Fabrication and fitting of ocular conformerV2629Prosthetic eye, other typeHCPCS codes not covered for indications listed in the CPB:Page 2 of 5
Eye Prosthesis - Medical Clinical Policy Bulletins AetnaV2627Scleral cover shells [trial scleral cover shells are notseparately payable]ICD-10 codes covered if selection criteria are met:Q11.1Other anophthalmos [congenital absence of eye]S05.00x -Injury of eye and orbitS05.92x Z90.01Acquired absence of eyeThe above policy is based on the following references:1. Alam S, Sugavaneswaran M, Arumaikkannu G, Mukherjee B. Aninnovative method of ocular prosthesis fabrication by bio-CADand rapid 3-D printing technology: A pilot study. Orbit.2017;36(4):223-227.2. Chin K, Margolin CB, Finger PT. Early ocular prosthesis insertionimproves quality of life after enucleation. Optometry.2006;77(2):71-75.3. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants inenucleation surgery: A report by the American Academy ofOphthalmology. Ophthalmology. 2003;110(10):2054-2061.4. Mattos BS, Montagna MC, Fernandes Cda S, Saboia AC. Thepediatric patient at a maxillofacial service: Eye prosthesis. BrazOral Res. 2006;20(3):247-251.5. NHIC, Corp. Eye prosthesis. Local Coverage Article A33613.Durable Medical Equipment Medicare Administrative Contractor(DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised April 1,2013.6. NHIC, Corp. Eye prosthesis. Local CoverageDetermination L11529. Durable Medical Equipment MedicareAdministrative Contractor (DME MAC) Jurisdiction A. Hingham,MA; NHIC; revised October 31, 2014.7. Song JS, Oh J, Baek SH. A survey of satisfaction in anophthalmicpatients wearing ocular prosthesis. Graefes Arch Clin ExpOphthalmol. 2006;244(3):330-335.8. Vincent AL, Webb MC, Gallie BL, et al. Prosthetic conformers: Astep towards improved rehabilitation of enucleated children. ClinExperiment Ophthalmol. 2002;30(1):58-59.Page 3 of 5
Eye Prosthesis - Medical Clinical Policy Bulletins AetnaPage 4 of 5Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits andconstitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan orprogram benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee anyresults or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetnaor its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may beupdated and therefore is subject to change.Copyright 2001-2021 Aetna Inc.
Eye Prosthesis - Medical Clinical Policy Bulletins AetnaPage 5 of 5AETNA BETTER HEALTH OF PENNSYLVANIAAmendment toAetna Clinical Policy Bulletin Number: 0619 Eye ProsthesisThere are no amendments for Medicaid.annual 10/01/2021
CPT Codes/ HCPCS Codes/ICD-10 Codes . Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by " " . Optometry. 2006;77(2):71-75. 3. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in . PDF/UA Created Date: 10/22/2021 11:53:30 AM .
