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Shane Posted Sat 03rd of August, 2013 02:34:49 AM

I read on CMS that DME covers contacts after caract surgery? I've never heard of that! True? If so, what are the differences in regards to claim requirements?

Shane Posted Sat 03rd of August, 2013 13:20:18 PM

As opposed to glasses.

Shane Posted Thu 08th of August, 2013 18:18:42 PM

Great answer to my other two recent questions. I suppose someone is working on this one?

SuperCoder Answered Thu 08th of August, 2013 21:57:07 PM

Thanks for writing in again! If you know about the glasses, then you pretty much understand the contact lenses, too. You should check to see whether your DME has a Refractive Lens policy. Look for distinct requirements for patients with IOL vs. aphakic without IOL. E.g., search L11522 under Document ID at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx to see the CGS policy. You’ll see one pair of contacts covered for a patient with IOL, but medical necessity drives replacement lens coverage for aphakic patients.

Medicare covers (patient pays 20%) one pair of eyeglasses or one set of contacts after each cataract surgery with an IOL (see http://www.medicare.gov/Pubs/pdf/10116.pdf and http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/VisionServices_FactSheet_ICN907165.pdf).

This coverage is based on the SSA (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm, 1861 (s) (8)): “The term “medical and other health services” means any of the following items or services:
prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices, and including ONE PAIR OF CONVENTIONAL EYEGLASSES OR CONTACT LENSES FURNISHED SUBSEQUENT TO EACH CATARACT SURGERY WITH INSERTION OF AN INTRAOCULAR LENS;”

Here’s what the Medicare Benefit Policy Manual has to say (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf section 120)

1. Prosthetic Cataract Lenses
One of the following prosthetic lenses or combinations of prosthetic lenses furnished by a physician (see §30.4 for coverage of prosthetic lenses prescribed by a doctor of optometry) may be covered when determined to be reasonable and necessary to restore essentially the vision provided by the crystalline lens of the eye:
* Prosthetic bifocal lenses in frames;
* Prosthetic lenses in frames for far vision, and prosthetic lenses in frames for near vision; or
* When a prosthetic contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), make payment for the contact lens(es) and prosthetic lenses in frames for near vision to be worn at the same time as the contact lens(es), and prosthetic lenses in frames to be worn when the contacts have been removed.

Lenses which have ultraviolet absorbing or reflecting properties may be covered, in lieu of payment for regular (untinted) lenses, if it has been determined that such lenses are medically reasonable and necessary for the individual patient. Medicare does not cover cataract sunglasses obtained in addition to the regular (untinted) prosthetic lenses since the sunglasses duplicate the restoration of vision function performed by the regular prosthetic lenses.

One pair of conventional eyeglasses or conventional contact lenses furnished after each
cataract surgery with insertion of an IOL is covered

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