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HealthPartners

Coverage criteria policies

Eyewear – Minnesota Health Care Programs

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.

Coverage

Eyeglasses and vision care services are generally covered subject to the indications listed below and per your plan documents.

  • The following MHCP enrolled provider may dispense eyeglasses and perform vision services within their scope of practice:
    • Ophthalmologist
    • Opticians
    • Optometrists.
  • It is the responsibility of the provider to verify eligibility of the member and determine when the last pair of MHCP eyeglasses was dispensed before providing services or ordering eyeglasses. 

Indications that are covered

  1. Comprehensive vision examinations
  2. Intermediate vision examinations
  3. One dispensing fee within a thirty (30) day period
  4. Eyeglass frames
  5. Deluxe eyeglass frames for adults with cognitive disabilities, seizure conditions or for children (a specific diagnosis is required for deluxe frames for members age 21 or older)
  6. Glass, plastic or polycarbonate lenses for children or adults (MHCP does not require children to have polycarbonate lenses)
  7. Tinted, U-V polarized or photochromatic lenses for certain childhood, visual, or seizure conditions when standard lenses may pose a risk (a specific diagnosis is required)
  8. High index lenses when the correction in either eye is plus or minus 6.00 diopters or greater
  9. Aspherical hand held magnifiers (3.7 X 11.0 diopter)
  10. Double segs (FT25, FT28), plastic or glass
  11. Fresnel prism, Slab off prism
  12. Repairs to frames and lenses
  13. Contact lenses for aphakia, keratoconus, or aniseikonia and for bandage lenses
Contact Lenses
  1. Contact lenses are covered when prescribed for aphakia, keratoconus, or aniseikonia and for bandage lenses. Bandage and Therapeutic Lenses: 92071 and 92072 (includes the supply of the contact lens). Claims for contact lenses for the same date of service will be denied. When performed bilaterally, bill two units on one line with modifier 50. Claims must include an appropriate diagnosis.
  2. Bilateral prescribing and fitting of contact lenses, except for aphakia codes: 92310 and 92314. Use modifier 52 when prescribing and fitting one eye.
  3. Contact lenses: S0500, V2500-V2599. One unit = one contact lens. Planned replacement contact lenses may be dispensed as multi-packs. The following dispensing limits apply:

    Type of Contact Lens

    HCPCS code

    Limit

    Disposable contact lens

    S0500

    1 month supply, up to 30 per eye per dispensing

    PMMA, gas permeable, gas impermeable contact lens

    V2500-V2513, V2530-V2599

    2 units (1 per eye) per dispensing

    Hydrophilic contact lens

    V2520-V2523

    1 multi-pack per eye, up to 12 units per dispensing

Please refer to the MHCP manual chapter referenced at the bottom of this policy for more detail on Eyeglasses, Eyeglass Frames, and Eyeglass lenses.

Receiving Eyeglasses More Frequently Than Every Two Years

It is expected that with reasonable care eyeglasses should not need to be replaced due to loss or damage more than once in a two year dispensing period. However, vision providers may dispense a new pair of eyeglasses, even though two years have not passed since a member's last pair was dispensed when one or more of the following reasons for medical necessity are met:

  1. There is a change in correction of 0.5 diopters or greater in either sphere or cylinder power in either eye.
  2. There is a shift in axis of greater than 10 degrees in either eye.
  3. A comprehensive or intermediate vision examination shows that a change in eyeglasses is medically necessary.
  4. A change in the member's head size warrants a new pair of eyeglasses.
  5. The member has had an allergic reaction to the previous pair of eyeglasses.
  6. The original pair is lost, broken, or irreparably damaged; the dispensing provider must obtain a written statement explaining this from the member (or the member’s caretaker), and send a copy of this documentation to the contract vendor with the order. If the original pair is lost, broken or damaged beyond repair, the eyeglasses will be replaced with an identical pair of eyeglasses, unless the identical frame is not available through the contract vendor. If a previous pair was ordered through the contract vendor, the contract vendor will notify the dispensing vendor that the eyeglasses will be replaced with an identical pair.

Documentation of medical necessity for the above situations must be kept in the member’s medical record. The reason for the replacement must be included on the order when new eyeglasses are ordered from the contract vendor.

Indications that are not covered

  1. Replacement of lenses or frames to change the style or color.
  2. Cosmetic services
  3. Tints or polarized lenses for fashion purposes. (Refer to the MHCP manual chapter referenced at the bottom of this policy for more detail on tinted or polarized Eyeglass Lenses.)
  4. Protective coating for plastic lenses.
  5. Edge and anti-reflective coating of lenses.
  6. Industrial, sport eyeglasses or glasses for computer screen usage, unless they are the member's only pair and are necessary for vision correction.
  7. Invisible bifocals or progressive bifocals.
  8. Contact lenses which require authorization when authorization was not obtained.
  9. Replacement of lenses or frames due to provider error in prescribing, frame selection, or measurement. Errors made in prescribing or dispensing are the responsibility of the prescribing or dispensing provider.
  10. Eyeglasses or lenses for occupational or educational needs, unless it is the member's only pair and it is necessary for vision correction
  11. Services or materials that are considered experimental or not clinically proven by prevailing community standards or customary practice.
  12. Backup eyeglasses or split prescription into two pairs of eyeglasses.
  13. Reading glasses without a prescription.
  14. Saline or other solutions for the care of contact lenses.

Definitions

Comprehensive Vision Examination: A complete evaluation of the visual system. The services include patient history, general medical observation, external and ophthalmoscopic examination, gross visual fields, basic sensorimotor examination, biomicroscopy, examination with cycloplegia or mydriasis, and tonometry.

Contract Vendor: The MHCP enrolled optical lab that supplies and assembles eyeglasses for MHCP members.

Dispensing Provider: The MHCP enrolled provider who orders eyeglasses and provides dispensing services to MHCP members.

Dispensing Services: The technical services (fitting of spectacles) necessary for the design, fitting, and maintenance of glasses (frames and lenses) as prescribed by an optometrist or ophthalmologist.

Eyeglass or Vision Service: A comprehensive or intermediate vision exam provided by an optometrist or ophthalmologist, or eyeglasses dispensed by an optician, optometrist or ophthalmologist.

Eyeglasses or Spectacles: A pair of lenses mounted in a frame to aid vision, as prescribed by an optometrist or ophthalmologist.

Intermediate Vision Examination: An evaluation of a new or existing specific visual problem complicated with a new diagnosis or management problem not necessarily relating to the primary diagnosis.

Ophthalmologist: A physician who has academic training in ophthalmology beyond the state requirements for licensure and experience in the treatment and diagnosis of the diseases of the eye.

Optician: A supplier of eyeglasses to a patient as prescribed by the patient's optometrist or ophthalmologist.

Optometrist: A person licensed as an optometrist under Minnesota law.

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.

References

MHCP Provider Manual Eyeglass and Vision Care Services revised 2-21-2017

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Policy activity

  • 01/01/1994 - Date of origin
  • 11/09/2017 - Effective date
Review date
  • 11/2017
Revision date
  • 11/09/2017

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