5160-6-11 Covered services and materials not purchased under the vision volume purchase contract.

(A) Low or subnormal vision aids: low vision aids are not purchased under the volume purchase contract. All low or subnormal vision aids require prior authorization and must be ordered from an optical laboratory of the provider's choice. To be reimbursed for low vision aids, the provider must use the appropriate healthcare common procedure coding system (HCPCS) level codes as follows:

(1) V2600 - Hand-held low vision aid and any other non-spectacle mounted aid;

(2) V2610 - Single-lens spectacle mounted low vision aid; or

(3) V2615 - Telescopic and other compound lens systems including: distance vision telescope, near vision telescopes, or compound lens systems.

(B) Ocular prostheses and prostheses services: Ocular prostheses and prostheses services require prior authorization and are not purchased under the volume purchase contract. To be reimbursed for ocular prostheses, the provider must use the appropriate HCPCS level codes as follows:

(1) V2623 - Prosthetic eye, plastic, custom;

(2) V2624 - Polishing/resurfacing of ocular prosthesis;

(3) V2625 - Enlargement of ocular prosthesis;

(4) V2626 - Reduction of ocular prosthesis;

(5) V2627 - Scleral cover shell;

(6) V2628 - Fabrication and fitting of ocular conformer; or

(7) V2629 - Prosthetic eye, other type.

(C) Contact lenses and contact lens services.

(1) Contact lenses and contact lens services are covered when prior-authorized by the Ohio department of job and family services (ODJFS). The department will authorize contact lenses under the following conditions:

(a) To correct aphakia.

(b) To correct high refractive errors, greater than ten diopters, when the visual acuity cannot be corrected to 20/70 in the better eye with spectacle lenses and there is a significant improvement in visual acuity with contact lenses.

(c) There is a high degree of anisometriopta where binocularity can be substantiated.

(d) To treat keratoconus, where there is a high corneal astigmatism or corneal irregularities when the visual acuity cannot be corrected to 20/70 in the better eye with spectacles and there is a significant improvement with contact lenses.

(2) Contact lenses are not purchased under the vision volume purchase contract. All contact lenses must be prior-authorized and then ordered from an optical laboratory of the provider's choice. The following codes are per lens and must be reported twice when the code is appropriate for both eyes. To be reimbursed for contact lenses, use the appropriate HCPCS level codes as follows:

(a) V2500 - Contact lens, PMMA, spherical, per lens;

(b) V2501 - Contact lens, PMMA, toric or prism ballast, per lens;

(c) V2510 - Contact lens, gas permeable, spherical, per lens;

(d) V2511 - Contact lens, gas permeable, toric, prism ballast, per lens;

(e) V2513 - Contact lens, gas permeable, extended wear, per lens;

(f) V2520 - Contact lens, hydrophilic, spherical, per lens;

(g) V2521 - Contact lens, hydrophilic, toric, or prism ballast, per lens;

(h) V2523 - Contact lens, hydrophilic, extended wear, per lens;

(i) V2530 - Contact lens, scleral, gas impermeable, per lens; or

(j) V2599 - Contact lens, other type.

(3) Contact lens services are reimbursable by billing the appropriate physicians' "Current Procedural Terminology (CPT)" code as referenced in rule 5101:3-1-60 of the Administrative Code. Contact lens services must be prior-authorized byODJFS.

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 5/9/88, 8/22/88 (Emer), 11/18/88, 7/1/93, 12/31/96 (Emer), 3/22/97, 7/1/02, 12/30/05 (Emer), 3/27/06