Chapter 525 Vision Services

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 1

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

TABLE OF CONTENTS

SECTION PAGE NUMBER

Background ......................................................................................................................................... 2

Policy .................................................................................................................................................. 2

525.1 Covered Services ............................................................................................................. 2

525.1.1 Eye Examinations ............................................................................................................. 2

525.1.2 Glasses and Frames ......................................................................................................... 2

525.1.3 Replacement Lenses ........................................................................................................ 3

525.1.4 Photochromatic Lenses..................................................................................................... 3

525.1.5 Contact Lenses ................................................................................................................. 3

525.1.6 Orthoptics/Pleoptic Training .............................................................................................. 4

525.1.7 Prosthetic Eye and Cataract Surgery ................................................................................ 4

525.2 Provider Participation and Enrollment Requirements ......................................................... 4

525.3 Nursing Facilities .............................................................................................................. 4

525.4 Psychiatric Residential Treatment Facility (PRTF) ............................................................. 5

525.5 Prior Authorization ............................................................................................................ 5

525.6 Non-Covered Services ...................................................................................................... 5

Glossary .............................................................................................................................................. 6

Change Log ......................................................................................................................................... 7

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 2

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

BACKGROUND

WV Medicaid covers vision care services for the examination, diagnosis, treatment, and management of

ocular and adnexal pathology. This includes diagnostic testing, treatment of eye disease or infection,

specialist consultation and referral, comprehensive ophthalmologic evaluations, and eye surgery (but not

cosmetic surgery). Visual examinations to determine the need for eyeglasses are covered for children

only.

POLICY

525.1 COVERED SERVICES

Covered vision services are available to enrolled children up to 21 years of age, and limited vision services

are available to enrolled adults 21 years of age and greater. There is no coverage for cosmetic purposes.

Prior authorization is required, when indicated, for specific services. Request for prior authorization does

not guarantee approval or payment.

Corrective vision services require a written order from an enrolled ophthalmologist or optometrist.

Documentation and a written order justifying the medical need for vision services must be maintained in

the individual’s clinical record for a minimum of five years and available to BMS or their designee upon

request. Service limits and prior authorization may apply.

525.1.1 Eye Examinations

Children up to 21 Years of Age

Eye examination(s) are based upon Early Periodic Screening, Diagnosis and Treatment (EPSDT)

referral(s), American Academy of Pediatrics (AAP) and Bright Futures requirements.

Adults 21 Years of Age or Greater

Eye examinations are limited to comprehensive exam/evaluation for medical necessity only. Visual

examinations to determine the need for eyeglasses are covered for children only. Additionally, diagnostic

evaluations and examinations may be reimbursed when documentation in the medical record justifies the

medical need for more frequent exams.

525.1.2 Glasses and Frames

Children up to 21 Years of Age

Vision services for the purpose of prescribing glasses/contact lenses, fitting, adjusting and replacing

glasses/contact lenses are covered.

Eyeglass frames are covered. Replacement of frames is covered when the frames can no longer be used

(e.g., broken) and repair costs exceed replacement costs. Frames must have a limited warranty. A limited

warranty must be utilized for frame replacement/repair when the warranty is applicable and cost effective.

Medicaid will not reimburse for both contact lenses and eyeglasses when eyeglasses can be worn.

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 3

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

Adults 21 Years of Age or Greater

One pair of eyeglass/frames is covered for members who had documented cataract extraction within the

past 60 days. Frames must have a limited warranty.

525.1.3 Replacement Lenses

Single, Bifocal, Trifocal Glass or Plastic Lens Lenses and Variable Asphericity Glass or Plastic Lens are

covered. Replacement of lens is based on the following criteria:

 Vertical prism change of 1 prism diopter or greater;

 Horizontal prism change of 3 prism diopter or greater;

 A change of .50 in the spherical equivalent of the member’s prescription;

 A change of the cylinder axis of at least: 10 degrees for under 1.00D cylinder, 5 degrees for 1.00D

to 2.00D cylinder or 2 l/2 degrees for 2.25D cylinder or greater;

 Any change which gives at least 1 line improvement on the standard vision acuity chart;

 Breakage or loss of lens; or

 Change in specific eye conditions.

525.1.4 Photochromatic Lenses

Children up to 21 Years of Age

Photochromatic Lenses are limited to diagnoses of albinism and pupillary defects.

525.1.5 Contact Lenses

The fitting, adjusting, and dispensing of contact lenses are included in the payment of the lenses.

Replacement of contact lenses is covered when the lenses can no longer be used. Contact lenses must

have a limited warranty. A limited warranty must be utilized for replacement of contact lenses when the

warranty is applicable and cost effective.

Children up to 21 Years of Age

Vision services for the purpose of prescribing glasses/contact lenses, fitting, adjusting and replacing

glasses/contact lenses are covered.

Medicaid will not reimburse for both contact lenses and eyeglasses when eyeglasses can be worn.

Contact lenses (hard, soft and gas-permeable) for children are limited to the following:

 Refractive error which is 9 diopters or greater in any meridian;

 Keratoconus;

 Anisometropia when the difference in power between 2 eyes is 3 diopters or greater;

 Aniseikonia

 Aphakia

Adults 21 Years of Age or Greater

Contact lenses for adults are covered only when 1 of the following conditions exists:

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 4

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

1. Keratoconus

2. Aphakia

525.1.6 Orthoptics/Pleoptic Training

Children Up to 10 Years of Age Only

Orthoptics and/or Pleoptic Training – Vision therapy is only covered for children under age 10 years for

treatment of strabismus and other disorders of binocular eye movements. Therapy is limited to a total of 6

sessions per calendar year. Prior authorization is required when service limits are exceeded. If

improvement is not noted after 4 sessions, the member must be referred to an appropriate professional

(e.g., neurologist or ophthalmologist) for further evaluation. A treatment plan is required. The therapy

treatment plan and regimen, such as patching, lens fogging, red/green/Polaroid filters, other lens devices,

is to be taught to the client, family, foster parents and/or caregiver during the therapy treatments. Training

is considered complete when 1 of the following goals is attained:

1. Subsequent services would be for maintenance of a functional ability; or

2. When the member has demonstrated no progress at 2 consecutive visits.

525.1.7 Prosthetic Eye and Cataract Surgery

An artificial eye prosthesis is covered with a prescription that identifies the type of artificial eye required and

summarizes the member’s need for such an eye. The member’s medical record must contain written

documentation of the provider’s evaluation leading to a recommendation for an artificial eye.

Providers must submit directly to the Medicare carrier on the appropriate claim form all charges for artificial

eyes or eyeglasses following cataract surgery which have been furnished to members with both Medicare

and Medicaid coverage.

525.2 PROVIDER PARTICIPATION AND ENROLLMENT REQUIREMENTS

West Virginia Medicaid recognizes enrolled ophthalmologists, optometrists, opticians, ocularists, and vision

service centers as eligible providers for covered vision services in accordance with their license and scope

of practice to enrolled Medicaid members. To be eligible for participation and reimbursement of covered

vision services, all providers must:

 Meet all applicable licensing, accreditation and certification requirements.

 Have a valid signed provider enrollment application/agreement on file;

 Meet and maintain all Bureau for Medical Services’ provider enrollment requirements; and

 Independent vision centers must also meet State and Local business rules and regulations.

Refer to Chapter 300, Provider Participation Requirements for additional information.

525.3 NURSING FACILITIES

Vision services are not eligible for reimbursement as a direct billing to Medicaid if the Medicaid member

is a resident of the nursing facility at the time the vision service is provided. Refer to Chapter 514, Nursing

Facility Services for additional information.

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 5

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

525.4 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)

Upon admission to a PRTF, the WV Medicaid member will receive a medical and a nursing assessment

which must be documented within 24 hours of admission. If during either of these assessments a more

detailed vision assessment is indicated or if there is evidence of vision impairment, (i.e., member wears

glasses) a more detailed vision examination must be scheduled. PRTF facilities must provide physical

health services (including vision services) as part of their treatment of WV Medicaid members and, as

such, are not separately reimbursed. Physical health services may be provided directly by the facility or

may be provided by a vendor outside the facility. Physical health services must be addressed on the

member’s treatment plan. Refer to Chapter 531, Psychiatric Residential Treatment Facility Services for

additional information.

525.5 PRIOR AUTHORIZATION

All requests for covered services requiring prior authorization must be submitted to the Utilization

Management Contractor (UMC) for medical necessity determination. Nationally accredited, evidence-

based, medically appropriate criteria, such as InterQual, or other medical appropriateness criteria

approved by BMS, is utilized for reviewing medical necessity of services requested.

Retrospective authorization is available by the UMC in the following circumstances:

 A procedure/service denied by the member’s primary payer, providing all requirements for the

primary payer have been followed, including appeal processes; or

 Retroactive West Virginia Medicaid eligibility.

Refer to Chapter 100, General Administration and Information for additional information.

525.6 NON-COVERED SERVICES

West Virginia Medicaid does not cover or separately reimburse the following vision services.

 Glasses with a prescription that is equal to or less than +/-0.25 diopters in both eyes

 Contact lenses when eyeglasses can be worn.

 Refraction

 Sunglasses of any kind

 Anti-reflective lenses

 Repair/replacement of frames/lenses for adult members 21 years of age and older

 Designer frames

 Other optional/deluxe features

 Fitting of spectacle mounted low vision aids, single element systems, telescopic or other compound

lens

 Cleaning supplies, cases, or miscellaneous items for glasses or contact lenses

 Simple, one-step adjustments or realignment of the frame or temples

 Fitting, adjustment, dispensing of eyeglasses and contact lenses, measurement of the member’s

anatomical facial characteristics, preparation of the prescription form, writing of laboratory

specifications, ordering the prescription, adjusting the visual axes and anatomical topography, and

other materials that make up the eyeglasses or contact lenses

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 6

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

 An evaluation and management and comprehensive or intermediate eye exams on the same day

for the same member by the same provider.

 Determination of the refractive state as it is included in an ophthalmological examination and may

not be billed as a separate service.

 Two pair of glasses in lieu of bifocals or trifocals in a single frame

 Extra or spare pairs of glasses or contacts

 Bifocals and trifocals segments over 28 mm including executive

 Nonprescription glasses

Non-covered services are not eligible for a DHHR fair hearing or desk/document review.

GLOSSARY

Definitions in Chapter 200, Definitions & Acronyms apply to all West Virginia Medicaid services, including

those covered by this chapter. Definitions in this glossary are specific to this chapter.

Albinism: A congenital disorder characterized by the complete or partial absence of pigment in the skin,

hair, and eyes due to absence or defect of an enzyme involved in the production of melanin.

Aniseikonia: A condition in which the shape and size of the ocular image differ in each eye

Anisometropia: The difference in refractive power of the two eyes in which the variance is at least 1 diopter

Aphakia: The absence of the lens of the eye, due to surgical removal, a perforating wound or ulcer, or

congenital anomaly

Cataract: Clouding of the lens of the eye which impedes the passage of light

Diopter: A measurement of refractive errors

Gonioscopy: A procedure using an ophthalmoscope to examine the angle of the anterior chamber of the

eye and for demonstrating ocular motility and rotation

Hydrophilic Contact Lens: Corrective lenses that are under the prosthetic device benefit for aphakia

Hydrophilic Contact Lens for Corneal Bandaging: The use of a hydrophilic contact lens to relieve pain,

promote healing, mechanical protection, maintain ocular surface hydration, treatment of keratoconus and/or

delivery of topical ocular medicine on the cornea. The lens is not paid separately.

Intraocular Lens: An artificial lens which may be implanted to replace the natural lens after cataract surgery

Keratoconus: A rare inherited condition of the cornea in which the cornea is steepened to the point of

being cone shaped

Lenticular Lens: A lens that is also known as myodisc, sometimes termed a minus lenticular lens and

utilized for very high negative corrections

CHAPTER 525 VISION SERVICES

BMS Provider Manual Page 7

Chapter 525 Vision Services Revised 9/1/2016

DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be

supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior

authorization requirements, service limitations and other practitioner information.

Macular Degeneration: A chronic condition that causes central vision loss

Mydriasis: A condition characterized by the prolonged and abnormal dilation of the pupil

Ocularist: An enrolled professional who performs the fitting and fabrication of ophthalmic prosthetics

Ophthalmodynamometry: The measuring of pressure on the sclera while the fundus is studied with an

ophthalmoscope

Ophthalmologist: An enrolled physician who specializes in the medical and surgical care of the eyes and

vision system and in the prevention of eye disease and injury and meets the qualifications set forth by the

West Virginia State Code or the State in which they practice and has a current valid license to practice

Ophthalmologist (Dispensing): An enrolled physician with an ophthalmology specialty that provides

frames, lens, and contacts in addition to ophthalmological covered medical and surgical services and meets

the qualifications set forth by the West Virginia State Code or the State in which they practice and has a

current valid license to practice. This physician requires 2 Medicaid provider numbers: 1 for medical and

surgical services and 1 for frames, lenses, and contacts.

Optometrist: An enrolled licensed professional that is trained to provide ocular evaluations and

examinations, prescribe corrective contact lenses and glasses, and diagnose and treat eye disease,

prescribe specific laboratory tests and ultrasound, and meets the qualifications set forth by the West Virginia

State Code or the State in which he/she practices and has a current valid license to practice.

Optician: A licensed health care practitioner who designs, fits and dispenses lenses and appliances for the

correction of a member's vision

Prosthesis: An artificial substitute for a missing body part, such as an eye, areas of the face, or ear; used

for functional and cosmetic reasons

Pseudophakia: A condition in which the eye has been fitted with an intraocular lens to replace the

crystalline lens, usually due to cataract surgery

Tonometry: The measuring of intraocular pressure

Vision Center: An eye care center that offers various services that may include examinations, fabrication,

fitting and dispensing of vision appliances

REFERENCES

West Virginia State Plan references vision services at sections 3.1-A(6)(b), 3.1-B(6)(b), supplement 2 to

attachments 3.1-A and 3.1-B(6)(b).

CHANGE LOG

REPLACE

TITLE

CHANGE DATE

EFFECTIVE DATE

Entire Chapter

Vision Services

September 1, 2016