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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 : 4.3.6.2 Contact Lenses

4.3.6.2
Prior authorization is required for all contact lenses. The following procedure codes may be reimbursed for prosthetic and nonprosthetic contact lenses:
 
 
The following procedure codes may be reimbursed for the fitting or modification of a contact lens:
 
 
Contact Fitting for Corneal Bandage
A contact lens fitting for the placement of a corneal bandage lens may be medically necessary for eye protection and pain control due to a disease process or an injury. Procedure codes 92071 and 92072 may be reimbursed for the fitting of the corneal bandage for treatment and management.
Procedure code 92071 is limited to once per eye by any provider. Modifier LT or RT must be included on the claim to identify the eye on which the service was performed. When procedure code 92071 is performed on both eyes on the same date of service, one procedure may be reimbursed at the full rate and the second procedure may be reimbursed at half rate.
Procedure code 92072 is limited to one service per lifetime by the same provider.
Procedure code 92072 will be denied if billed on the same date of service by the same provider as procedure code 92071.
Prior Authorization Requirements
Nonprosthetic contact lenses and corneal plano bandage lenses must be prior authorized. The following documentation must be submitted with a request for nonprosthetic contact lenses and must be signed and dated by the prescribing physician or optometrist:
Include a brief statement addressing the medical necessity for vision correction by contact lens(es) and specify why eyeglasses are inappropriate or contraindicated for this client
For the contact fitting of the corneal bandage lens (procedure code 92071 or 92072), nonprosthetic contact lenses for nonemergency placement require prior authorization that must be obtained before the lenses are dispensed. Documentation submitted with the request must include the information listed above.
Nonprosthetic contact lenses for emergency placement do not require prior authorization. The emergency condition necessitating a corneal bandage must be documented on the claim.
Additional nonprosthetic contact lenses may be considered more frequently than the limitations outlined in this handbook when documentation in the client’s medical record supports medical necessity for a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes.

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