CommercialCoverageMedium impact
Eye Prosthesis (CPB 0619, reviewed 2026-09-24)
Aetna·Ophthalmology, Optometry, Oral & Maxillofacial Surgery·Medical Policy
We identified it
Oct 4, 2026
Summary
Aetna's Eye Prosthesis policy (CPB 0619) was reviewed on September 24, 2026, clarifying coverage for eye prostheses, polishing/resurfacing, replacements every 5 years, and one modification (enlargement or reduction). The policy specifies covered HCPCS codes (V2623-V2629) and includes scleral cover shells under specific conditions. This is a policy clarification/reaffirmation with no substantive changes indicated from the previous version dated October 31, 2014.
Action Required
REQUIREMENTS:
- Billing team must verify that claim submission for eye prosthesis services uses only the covered HCPCS codes listed (V2623, V2624, V2625, V2626, V2627, V2628, V2629) paired with appropriate ICD-10 diagnosis codes
- Update coding guidelines to enforce that replacement prostheses are covered every 5 years unless additional medical necessity documentation is submitted (progressive socket changes, anophthalmic syndrome, pediatric growth)
- Implement claim validation logic to flag claims for more than one enlargement or reduction per prosthesis, requiring prior documentation of progressive socket changes or pediatric growth needs for approval
- Ensure polishing/resurfacing (V2624) is billed only twice yearly per policy
- Train billing staff that scleral cover shells (V2627) require documentation supporting orbital tissue support indication (e.g., sightless/shrunken eye from inflammatory disease)
- No immediate deadline specified; implement before next claim submission cycle to prevent denials on non-compliant submissions