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HealthPartners

Coverage criteria policies

Eyewear for children

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for eyewear for children.

This benefit applies to a limited number of HealthPartners plans. Please call Member Services or check your plan documents to determine whether this benefit applies to you.

Coverage

One pair of eyeglasses or contact lenses is covered per calendar year for children up to the age of nineteen (19) subject to the indications listed below and per your plan documents.

Indications that are covered

For children up to the age of nineteen (19):

  1. One pair of eyeglasses from the HealthPartners Eyewear Collection; or
  2. One pair of contact lenses and up to two contact lenses fittings are covered per calendar year.

Eyeglasses include:

  1. One frame from the designated HealthPartners Eyewear Collection.
  2. One set of prescription lenses.
  3. Anti-scratch coating.

Indications that are not covered

  1. Frames that are not included in the designated HealthPartners Eyewear Collection are not covered. However, one pair of lenses will be covered if a member chooses frames outside the HealthPartners Eyewear collection.
  2. More than one pair of lenses or frames or contacts per calendar year, regardless of the reason. This includes loss, breakage, theft, or change in member’s prescription.
  3. Safety glasses or goggles for sports or vocational reasons.
  4. Upgrades for UV protection, no-line multifocal lenses, etc.

Definitions

HealthPartners Eyewear Collection- a predetermined set of frames from which members may choose for coverage under the pediatric vision benefit.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

92310

Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation, corneal lens, both eyes, except for aphakia

92314

Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia

V2020

Frames, purchases

V2025

Deluxe frame

V2100

Sphere, single vision, plano to plus or minus 4.00, per lens

V2101

Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens

V2102

Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens

V2103

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2104

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2105

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2106

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2107

Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens

V2108

Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2109

Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2110

Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per lens

V2111

Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2112

Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder, per lens

V2113

Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2114

Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens

V2115

Lenticular (myodisc), per lens, single vision

V2118

Aniseikonic lens, single vision

V2121

Lenticular lens, per lens, single

V2199

Not otherwise classified, single vision lens

V2200

Sphere, bifocal, plano to plus or minus 4.00d, per lens

V2201

Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens

V2202

Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens

V2203

Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2204

Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2205

Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2206

Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2207

Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

V2208

Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2209

Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2210

Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

V2211

Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2212

Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

V2213

Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2214

Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens

V2215

Lenticular (myodisc), per lens, bifocal

V2218

Aniseikonic, per lens, bifocal

V2219

Bifocal seg width over 28mm

V2220

Bifocal add over 3.25d

V2221

Lenticular lens, per lens, bifocal

V2299

Specialty bifocal (by report)

V2300

Sphere, trifocal, plano to plus or minus 4.00d, per lens

V2301

Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens

V2302

Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens

V2303

Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2304

Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens

V2305

Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens

V2306

Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2307

Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

V2308

Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2309

Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2310

Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

V2311

Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2312

Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

V2313

Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2314

Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens

V2315

Lenticular, (myodisc), per lens, trifocal

V2318

Aniseikonic lens, trifocal

V2319

Trifocal seg width over 28 mm

V2320

Trifocal add over 3.25d

V2321

Lenticular lens, per lens, trifocal

V2399

Specialty trifocal (by report)

V2410

Variable asphericity lens, single vision, full field, glass or plastic, per lens

V2430

Variable asphericity lens, bifocal, full field, glass or plastic, per lens

V2499

Variable sphericity lens, other type

S0580

Polycarbonate lens (list this code in addition to the basic code for the lens)

V2782

Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens

V2783

Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens

V2784

Lens, polycarbonate or equal, any index, per lens

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

Items must be received from a contracted vendor or provider.

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Policy activity

  • 10/15/2013 - Date of origin
  • 10/01/2016 - Effective date
Review date
  • 10/2017

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