Does S0516 require prior authorization?

No, S0516 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S0516?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S0516`, Safety eyeglass frames

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For myopia management lenses (MiSight 1 Day), documentation of patient age at initiation (8–12 years), refraction (-0.75 to -4.00 D spherical equivalent) and astigmatism ≤ 0.75 D, and that lenses are prescribed/managed by a qualified eye care professional.
For Acuvue Abiliti Overnight, documentation of refractive error (≤ -4.00 D) and astigmatism (≤ 1.50 D), corneal topography/fitting records and that fitting was performed per manufacturer/clinical guidelines.

When requesting replacements after cataract surgery for Medicare members, documentation consistent with CMS requirements for consideration of replacement of lost or broken contact lenses or eyeglasses.

Medical record documentation of the diagnosis (e.g., aphakia, cataract extraction status, corneal disease ICD-10 codes) to support medical necessity.

Documentation of recent cataract surgery or congenital aphakia history when requesting prosthetic lenses for aphakia (including whether an intraocular lens has been implanted).

For replacement lenses covered due to change in physical condition, documentation describing the change in the member's physical condition (not refractive change) that necessitates replacement.

Key Coverage Criteria

Lenses made of polycarbonate or other impact-resistant materials (e.g., Trivex) for members with functional vision in only one eye.
Replacement eyeglasses under plans with a pediatric vision benefit when one or more of the following are met: (a) there is a change in refractive error; (b) with regular use the previous eyeglasses were broken or marred to a degree significantly interfering with vision or eye safety; (c) eyeglasses are replaced because a different frame size or shape is necessary due to the child's growth, metal allergy or other justifiable medical reasons.
Prosthetic external lenses (contacts or spectacles) and intraocular lenses medically necessary after cataract surgery to replace the crystalline lens (aphakia), including post-surgical external lenses customarily used during convalescence from cataract removal surgery.
Intraocular lenses as a medically necessary prosthesis for individuals lacking an organic lens because of surgical removal (e.g., cataract surgery) or congenital absence (congenital aphakia).
Bifocal spectacles, or spectacles for far vision or for near vision, when used to essentially restore vision provided by the crystalline lens after cataract surgery (aphakia).
Contact lenses for far vision (including binocular and monocular aphakia), including both contact lens(es) and spectacles for near vision that are worn simultaneously with the contact lenses or when the contact lenses have been removed (aphakia).

3 Active Policies

AETNA-CPB-0126, Contact Lenses and Eyeglasses

AETNA-CPB-0623, Safety Items

AMBETTER-CP.VP.06, Medically Necessary Optical Hardware

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S0516, Safety eyeglass frames