Page 140 - Medicare Benefit Policy Manual

This provision is effective for items replaced on or after April 1, 2001. It supersedes any
rule that that provided a 5-year or other replacement rule with regard to prosthetic
devices.

B. Prosthetic Lenses

The term “internal body organ” includes the lens of an eye. Prostheses replacing the lens
of an eye include post-surgical lenses customarily used during convalescence from eye
surgery in which the lens of the eye was removed. In addition, permanent lenses are also
covered when required by an individual lacking the organic lens of the eye because of
surgical removal or congenital absence. Prosthetic lenses obtained on or after the
beneficiary’s date of entitlement to supplementary medical insurance benefits may be
covered even though the surgical removal of the crystalline lens occurred before
entitlement.

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.

2. Payment for Intraocular Lenses (IOLs) Furnished in Ambulatory Surgical
Centers (ASCs)

Effective for services furnished on or after March 12, 1990, payment for intraocular
lenses (IOLs) inserted during or subsequent to cataract surgery in a Medicare certified