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45.4.6 Prosthetic Eyewear
Postsurgical prosthetic lenses are those lenses that replace the function of the eye's organic lens. Replacement may be necessary because of a congenital defect or trauma. However, the most frequent cause is surgical cataract extraction. The lenses can be contact lenses, eyeglasses, or both. The date of cataract surgery is not required on claims for permanent postsurgical prosthetic eyewear. The date of surgery is required to determine the convalescence period for temporary prosthetic eyewear. Contact lenses required as a postsurgical prosthetic may be supplied without prior authorization. Claims for temporary lenses are not payable, if dispensed after the four-month convalescence period. Claims for temporary eyewear that do not include the date of surgery are listed on the R&S as a claim in process and must be resubmitted for consideration of payment. Electronic claims of this type will be rejected. A letter with the rejection reason and instructions for resubmission will be mailed to the provider the following business day. Surgery dates on electronic claims must be identified in the appropriate fields of an approved electronic claims format.
The name of the surgeon who performed the cataract surgery is not required on claims for postsurgical prosthetic eyewear.
The Texas Medicaid Program provides as many temporary prosthetic lenses (contacts or eyeglasses) as necessary during the postsurgical convalescence period (up to four months after surgery) and one pair of permanent prosthetic contact lenses, eyeglasses, or both, in a lifetime (exceptions include replacements and new prosthetic eyewear when there is a significant change in visual acuity).
Contact lenses required as a postsurgical prosthetic may be supplied without prior authorization. Procedure codes for temporary postsurgical prosthetic lenses must be used only during the four-month convalescence period. After the convalescence period, procedure codes for permanent prosthetic eyewear must be used.
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