Durable Medical Equipment

Important Note:

HMSA has partnered with EyeMed, service date effective January 1, 2022. HMSA transitioned our current vision portfolio to a new vision benefit with EyeMed for the following line of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees. HMSA will continue to be the administrators for non-routine vision services through the members medical plan(s). For more information, please contact EyeMed at www.eyemedinfocus.com

Contact by phone:
For Providers 1-888-259-4344

HMSA policies and procedures regarding billing requirements and claims filing instructions for durable medical equipment (DME) are consistent with Medicare DME policies except where otherwise specified in the Provider E-Library.

Ophthalmological Benefits

Vision appliances, including contact lenses, are covered as a prosthetic device as outlined in the DME MAC Jurisdiction D Supplier Manual. Eye examinations and appliances for routine refraction are not covered as a medical benefit, but may be covered as a benefit of the member's vision rider, if applicable.

Covered items include:

• Scleral cover shells. Scleral cover shells (HCPCS code V2627) will be considered for coverage as a DME medical benefit when they are medically necessary as an artificial support to a shrunken and sightless eye or as a protective barrier in the treatment of severe dry eye.
• Refractive lenses. Refractive lenses, including hydrophilic contact lenses (HCPCS, V2520-V2523) are covered as a DME medical benefit when they are medically necessary to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence. Covered diagnoses are limited to pseodophakia (ICD-9-CM code V43.1; ICD-10-CM code Z96.1), aphakia (ICD-9-CM, 379.31; ICD-10-CM, H27.01,H27.02, H27.03), and congenital aphakia (ICD-9-CM, 743.35; ICD-10-CM, Q12.3). Lenses provided for other diagnoses will be denied as noncovered.

Claims Filing Information

Claims for scleral cover shells and refractive lenses must be submitted with a site-specific modifier - LT and/or -RT and modifier SC to indicate medical necessity and may require additional documentation. Some DME items also require benefit precertification or a certificate of medical necessity. For specific coverage and payment rules, please refer to the DME MAC Jurisdiction D Online Supplier Manual . The manual is available online at www.noridianmedicare.com/dme/news/manual/index.html.

Medicare Advantage Requirements

For an item to be covered by Medicare Advantage, a written signed and dated order must have been received by the supplier prior to the item being dispensed and a claim being filed. As Medicare Advantage is Medicare-based, DMERC/Medicare filing guidelines apply.

Revision History