CSHCN 2009 > Vision Related Services > Benefits, Limitations, and Authorization Requirements

35.2.1 Frames, Lenses, and Contact Lenses

The CSHCN Services Program will consider one form of eyewear for reimbursement per calendar year.

Frames must meet the following specifications:

•The provider must offer a minimum of three styles appropriate to the client's age or gender.

•The provider must offer frames in sizes appropriate to the client's needs.

•The provider must offer frames in a choice of three colors.

•Frames must be composed of all zylonite components. Clients or families may choose frames that are metal or a combination of zylonite and metal if they are willing to pay the difference between the CSHCN Services Program's reimbursement for zylonite frames and the cost of metal or metal and zylonite frames.

•Frames must meet statutory quality standards and must be made of new materials.

Lenses must meet the following specifications:

•Made of clear glass or plastic.

•Heat or chemically treated dress eyewear able to meet standards of the American National Standards Institute (which can be obtained at www.ansi.org) for first quality glass and plastic lenses.

•Heat or chemically treated dress eyewear able to meet standards of the American Standard Prescription Requirements for first quality glass and plastic lenses.

•Composed of new materials.

•A minimum of 22 mm flat top or equivalent for bifocals.

•A minimum flat top 7/25 lens or equivalent if trifocal.

•Medical necessity met for high-power and contact lenses.

If a client wants frames or lenses that exceed the benefit limitations, the client must pay the difference between the CSHCN Services Program allowed amount and the actual cost. CSHCN Services Program clients or parents or guardians must acknowledge that their choice exceeds the program requirements by signing the "CSHCN Services Program Vision Care Eyeglass Client Certification Form." A copy of this form is provided in Appendix B on page B-111 (English) and on page B-112 (Spanish). Providers must maintain a copy of this signed form in the client's medical record. The provider may withhold the noncovered eyewear until the client pays for the difference. If the client fails to pay for the noncovered items within 3 months, the provider may return any reusable items to stock. Any payment made by the CSHCN Services Program must be refunded to the CSHCN Services Program. When the eyewear is delivered, providers must have a client or the client's representative complete and sign the form entitled "CSHCN Services Program Documentation of Receipt" which is available in Appendix B on page B-100 (English) or page B-101 (Spanish). The date of delivery on the form is the date of service that should appear on the claim. The provider should retain this form and not submit it with the claim. Providers must maintain a copy of this form in their files for the life of the piece of equipment or until the equipment is authorized for replacement.

High-power lenses are defined as having a sphere equal to or greater plus or minus 7 diopters or a cylinder of plus or minus 4 diopters. High-power lenses are restricted to diagnosis codes 3670, Hypermetropia, 3671, Severe myopia, and 36720, Astigmatism.

High-index lenses allow lighter weight lenses for clients whose prescriptions result in unusually heavy lenses and are benefits of the CSHCN Services Program.

Polarization of lenses prevents damage to the eye from ultraviolet rays. Polarization of lenses is a benefit of CSHCN Services Program.

Polycarbonate lenses add extra strength to eyewear and are benefits of the CSHCN Services Program.

For custom-made eyewear, if the provider is notified before the eyewear is complete or delivered that the client has died or the prescription has changed, the provider may be reimbursed for furnished services and materials used up to the time the order is canceled. This applies only to the custom items. Noncustom or items not made to order for the specific client will not be considered for reimbursement.

Ophthalmologists, optometrists, and opticians may submit procedure codes V2020 and V2025 for reimbursement of frames.

Ophthalmologists, optometrists, and opticians may submit the following procedure codes for reimbursement of lenses:

Note: Providers should submit a quantity of two for a pair of lenses and use modifiers VP (aphakic lenses) and RB (repair or replacement of frames or lenses) as needed.

Ophthalmologists, optometrists, and opticians should submit the following procedure codes to request reimbursement for contact lenses:

The above procedure codes must be submitted with one of the following diagnosis codes to be considered for reimbursement:

Procedure codes V2410 and V2430 must be submitted in addition to the procedure codes for contact lenses when the provider is requesting reimbursement for aspheric contact lenses.

Contact lenses are sometimes used as corneal bandages to prevent blindness in an eye affected by a disease process. Ophthalmologists and optometrists should use procedure code 92070 in addition to the contact lens procedure codes when contact lenses are prescribed for this purpose.

Scleral lenses should be submitted using procedure code V2530 or V2531. Scleral lenses, when prescribed as a liquid bandage, should be submitted using procedure code S0515.