Medicare AdvantageDocumentationMedium impact
MA05.050c, Eye Prostheses and Scleral Cover Shell
Independence Blue Cross·Ophthalmology, Optometry·Medical Policy
Effective date
Apr 20, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross clarified medically necessary criteria for eye prostheses and scleral cover shells to align with CMS recommendations, effective April 20, 2026. The policy intent remains unchanged, but billing teams must ensure documentation meets updated standards for polishing/resurfacing (twice yearly), enlargements/reductions (first without documentation, additional requiring medical record support), and trial scleral cover shells (non-billable, included in final shell reimbursement).
Action Required
By April 20, 2026: Billing team must update claim submission procedures and documentation requirements for Independence Blue Cross Medicare Advantage members. (1) Ensure providers maintain contemporaneous written orders signed and dated before claim submission—do not accept retrospective orders during audits. (2) For prosthesis polishing/resurfacing (V2624), confirm member has received service twice per year only. (3) For prosthesis enlargements (V2625) or reductions (V2626), submit first modification without additional documentation; for subsequent modifications, attach medical record documentation justifying medical necessity. (4) For scleral cover shells (V2627), include diagnosis documentation confirming either sightless/shrunken eye from inflammatory disease OR dry eye condition. (5) Do NOT bill separately for trial scleral cover shells (code L9900); ensure they are included in the final shell reimbursement (V2627). (6) Maintain delivery confirmation on file (commercial carrier proof or member-signed receipt from DME supplier) prepared at time of delivery. Failure to meet these documentation requirements will result in claim denials during audits.