Vision Services

INDIANA HEALTH COVERAGE PROGRAMS

PROVIDER REFERENCE MODULE

Vision Services

LIBRARY REFERENCE NUMBER: PROMOD00051 PUBLISHED: JULY 7, 2022 POLICIES AND PROCEDURES AS OF APRIL 1, 2022 VERSION: 6.0

? Copyright 2022 Gainwell Technologies. All rights reserved.

Revision History

Version 1.0 1.1 1.2

2.0 3.0 4.0 5.0 6.0

Date

Policies and procedures as of Oct. 1, 2015 Published: Feb. 25, 2016

Policies and procedures as of April 1, 2016 Published: Dec. 15, 2016

Policies and procedures as of April 1, 2016 (CoreMMIS updates as of Feb. 13, 2017) Published: March 28, 2017

Policies and procedures as of April 7, 2017 Published: Oct. 26, 2017

Policies and procedures as of Aug. 1, 2018 Published: April 9, 2019

Policies and procedures as of Feb. 1, 2020 Published: June 25, 2020

Policies and procedures as of Jan. 1, 2021 Published: March 23, 2021

Policies and procedures as of April 1, 2022 Published: July 7, 2022

Reason for Revisions New document

Scheduled update

CoreMMIS updates

Completed By FSSA and HPE

FSSA and HPE

FSSA and HPE

Scheduled update

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update

FSSA and Gainwell

Scheduled update: ? Reorganized and edited text as needed for clarity ? Updated web links ? Updated the Introduction section ? Updated the Intraocular Stents section ? Updated the Intraocular Lenses section ? Added a code to the Triamcinolone Acetonide section

FSSA and Gainwell

Library Reference Number: PROMOD00051

iii

Published: July 7, 2022

Policies and procedures as of April 1, 2022

Version: 6.0

Table of Contents

Introduction ................................................................................................................................ 1 Prior Authorization for Vision Services.....................................................................................1 Vision Benefit Limits.................................................................................................................2 Billing and Reimbursement for Vision Services ........................................................................2 Eye Examinations ......................................................................................................................2 Diagnostic Services....................................................................................................................3 Eyeglasses ..................................................................................................................................3

Repair or Replacement of Eyeglasses .................................................................................4 Lenses .................................................................................................................................4 Frames ................................................................................................................................. 5 Contact Lenses ...........................................................................................................................6 Orthoptic or Pleoptic Training, Vision Training, and Therapies................................................6 Ophthalmologic Surgeries..........................................................................................................7 Intraocular Stents ................................................................................................................7 Intraocular Lenses...............................................................................................................7 Corneal Tissue ....................................................................................................................7 Vitrectomy ..........................................................................................................................7 Physician-Administered Ophthalmologic Drugs........................................................................8 Voretigene Neparvovec-rzyl (Luxturna).............................................................................8 Triamcinolone Acetonide....................................................................................................9 Fluocinolone Acetonide Intravitreal Implant (Retisert) ......................................................9

Library Reference Number: PROMOD00051

v

Published: July 7, 2022

Policies and procedures as of April 1, 2022

Version: 6.0

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