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2012 Texas Medicaid Provider Procedures Manual

Vision and Hearing Services Handbook : 4. Vision Care Professionals : 4.3 Services, Benefits, Limitations, and Prior Authorization : 4.3.7 Vision Services for Prosthetic Eyewear

4.3.7
Definition: Prosthetic eyeglasses or contact lenses are lenses that replace the eye’s organic lens when it is absent due to congenital or acquired aphakia. Aphakia may be the result of a congenital abnormality or defect or an acquired condition as a result of trauma or cataract removal.
Limitations: Prosthetic eyeglasses or contact lenses may be provided based on medical necessity. Eye examinations and prosthetic eyewear may be reimbursed as follows:
Replacement of prosthetic eyeglasses or contact lenses may be reimbursed for clients of any age due to loss or destruction of the eyewear or due to a significant change in visual acuity with a diopter change of 0.5d or more in the sphere, cylinder or prism measurements. The provider must maintain in the client’s medical record documentation that supports the medical necessity for the replacement eyeglasses or contact lenses.
Prosthetic eyeglasses or contact lenses may be reimbursed when billed with modifier VP and one of the following aphakia diagnosis codes:
Refer to:
Subsection 4.3.6, “Vision Services for Nonprosthetic Eyewear” in this handbook for the eyeglass lens, frame, and contact lens procedure codes and dispensing requirements that apply to prosthetic and nonprosthetic eyewear.
Prior authorization is not required for prosthetic eyeglasses or contact lenses.
The date of cataract surgery is not required on the claim for permanent prosthetic eyeglasses.

Texas Medicaid & Healthcare Partnership
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