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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 4 Vision Care Professionals : 4.3 Services, Benefits, Limitations, and Prior Authorization : 4.3.6 Nonprosthetic Eyeglasses or Contact Lenses

4.3.6
Nonprosthetic eyeglasses or contact lenses are lenses that are medically necessary to correct defects in vision when the eye’s organic lens is present. Providers may refer to TAC §354.1015 for more information.
Nonprosthetic eyeglasses or contact lenses may be reimbursed for clients of any age when there is no other option available to correct or ameliorate a visual defect. Contact lenses require prior authorization with documentation of medical necessity. Prescribing and dispensing medically necessary eyeglasses or contact lenses are benefits of Texas Medicaid as follows:
Nonprosthetic eyeglasses or contact lenses may be reimbursed once every 24 months. Additional services within the 24-month period may be considered when documentation in the client’s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. A new 24 month benefit period for eyewear begins with the placement of the new nonprosthetic eyewear.
Replacement of nonprosthetic eyeglasses or contact lenses because of loss or destruction is a benefit of Texas Medicaid for clients who are birth through 20 years of age. If the eyeglasses or contact lenses are lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and the signed form must be maintained in the client’s medical record.
For clients who have had insertion of an intraocular lens (IOL), one pair of eyeglasses or contact lenses may be reimbursed. Additional eyeglasses or contact lenses may be considered when documentation in the client’s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes.
Note:
Refer to:
Subsection 4.3.5.1, “Routine Vision Testing” in this handbook for information about vision testing for the purposes of prescribing eyewear.
The prescription for eyeglasses must be given to the client upon request. A provider may not withhold a prescription for eyeglasses from a client even if Medicaid reimbursement for the eye examination has not been received.
To be considered by Texas Medicaid, the eyeglasses or contact lenses must be:
In compliance with eyeglass program specifications for frames and lenses as stated in TAC Rule 354.1017, Specifications for Eyewear and Rule 363.503, Specifications for Eyewear.
Note:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.