CommercialCoverageMedium impact
Eye Prosthesis (CPB 0619, reviewed 2025-12-11)
Aetna·Ophthalmology, Optometry, Oral & Maxillofacial Surgery·Medical Policy
Effective date
Jun 18, 2002
We identified it
Aug 17, 2026
Summary
Aetna's eye prosthesis policy (CPB 0619) establishes medical necessity criteria for prosthetic eye services, including coverage for custom plastic prostheses, polishing/resurfacing twice yearly, replacement every 5 years, and one enlargement/reduction. Trial scleral cover shells (V2627) are NOT separately payable. This policy has been in effect since 2002 but was reviewed and reaffirmed on 2025-12-11.
Action Required
Immediately: Billing team must ensure claims for eye prosthesis services align with Aetna's medical necessity criteria. (1) Verify that V2627 (scleral cover shells) is NOT billed separately—trial shells are bundled into scleral cover shell allowance; deny any separate V2627 claims. (2) Implement frequency limits in billing system: polishing/resurfacing (V2624) limited to twice yearly, replacement (V2623) limited to every 5 years unless medical necessity documentation supports more frequent replacement, and enlargement/reduction (V2625, V2626) limited to one procedure unless documentation supports additional procedures as medically necessary. (3) Update prior authorization protocols to require supporting documentation for any services exceeding these frequency limits before claim submission. (4) Train billing and authorization staff on medical necessity criteria: eye prosthesis covered only for absence or shrinkage due to trauma, surgical removal, or congenital defect. Claims submitted without proper frequency compliance or medical necessity documentation will be denied.