Contact Lenses

Bandage lenses and contact lenses are covered without authorization if prescribed for aphakia, keratoconus, aniseikonia. All other diagnoses/conditions require authorization for all contact lens codes S0500 and V2500 – V2599, bandage lens code S0515, and contact lens treatment services codes 92071, 92072, and 92310 – 92326. Submit the following when an authorization is required to document medical necessity:

1. Diagnosis
2. Prescription
3. Documentation of medical necessity with a detailed explanation of why eyeglasses do not meet the needs of the member

Claims for contact lenses for the same DOS will be denied. When performed bilaterally, bill two units on one line with modifier 50. An appropriate diagnosis must be included.

Bandage/Therapeutic Lenses: 92071 and 92072. Both codes include the supply of the contact lenses. Claims for contact lenses for the same DOS will be denied. When performed bilaterally, bill two units on one line with modifier 50. Must include an appropriate diagnosis.

Bilateral prescribing/fitting of contact lenses except for aphakia: 92310 and 92314. Use modifier 52 when prescribing and fitting one eye.

Contact lenses: S0500, V2500 – V2599. One unit = one contact lens. Planned replacement contact lenses may be dispensed as multi-packs. Authorization is always required when prescribed for conditions other than aphakia, keratoconus, or aniseikonia or bandage lenses. The following additional dispensing limits apply:

PW_11-19_571
Updated_07/26/2023