Does V2627 require prior authorization?

No, V2627 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for V2627?

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

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`V2627`, Scleral cover shell

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

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted for items addressed in this policy.
For DMEPOS base items that require a WOPD, the supplier must have received a signed SWO/WOPD before delivering the DMEPOS item to the beneficiary.

For DMEPOS base items with separately billed associated options/accessories/supplies, the WOPD must list the base item and may list associated separately billed items prior to delivery.

Claims must be correctly coded per CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; refer to the LCD-related Standard Documentation Requirements Article and LCD-related Policy Article for additional documentation rules.

Key Coverage Criteria

Eye prosthesis is covered for a beneficiary with absence (anophthalmia) or shrinkage (phthisis) of an eye due to birth defect, trauma, or surgical removal (enucleation/evisceration).
Polishing and resurfacing of an ocular prosthesis (HCPCS V2624) is covered up to twice per calendar year.
One enlargement (HCPCS V2625) or one reduction (HCPCS V2626) of an ocular prosthesis is covered without additional documentation.
Covered items must be within a defined Medicare benefit category and be reasonable and necessary for diagnosis/treatment or to improve functioning of a malformed body member per Social Security Act §1862(a)(1)(A).
Aetna considers eye prostheses medically necessary for members with an absence or shrinkage of an eye due to trauma, surgical removal, or congenital defect.
Twice-yearly polishing and re-surfacing of eye prosthesis is medically necessary.

8 Active Policies

HUMANA-PROSTHETICS-KY-MEDICAID, Prosthetics

HUMANA-OCULAR-SURFACE-DISEASE-DIAGNOSIS-AND-TREATMENTS-MA, Ocular Surface Disease Diagnosis and Treatments

L33737, Eye Prostheses

AETNA-CPB-0619, Eye Prosthesis

BCBSIL-DME104.003, Scleral Shell

BCBSMT-DME104.003, Scleral Shell

BCBSNM-DME104.003, Scleral Shell

BCBSOK-DME104.003, Scleral Shell

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V2627, Scleral cover shell