L33793 · Refractive Lenses
Version 20. CMS effective date 10/01/2020. CMS updated 10/09/2020. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
HCPCS · Medicare DME
V2020 Medicare coverage
FRAMES, PURCHASES
Long description on the CMS LCD code table, this read.
Data read from the CMS Coverage API on 2026-10-13. The LCD version is the current final DME MAC LCD on that read. Text below is quoted from those CMS documents. Nothing here is a coverage rule Verzi wrote.
Coverage, in CMS's words
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33793 version 20, effective 10/01/2020. CMS LCD L33793.
National coverage indication, NCD 80.4
Hydrophilic contact lenses are eyeglasses within the meaning of the exclusion in §1862(a)(7) of the Social Security Act and are not covered when used in the treatment of non-diseased eyes with spherical ametrophia, refractive astigmatism, and/or corneal astigmatism. Payment may be made under the prosthetic device benefit, however, for hydrophilic contact lenses when prescribed for an aphakic patient. Medicare Administrative Contractors are authorized to accept a Food and Drug Administration (FDA) letter of approval or other FDA-published material as evidence of FDA approval. (See §80.1 for coverage of a hydrophilic lens as a corneal bandage.)
Excerpt from NCD 80.4 version 1. CMS NCD 80.4.
Governing LCD
Governing NCD
NCD 80.4 · Hydrophilic Contact Lenses
Current version on the CMS national report: 1. Effective date This is a longstanding national coverage determination. The effective date of this version has not been posted.. Benefit category: Prosthetic Devices.
Documentation requirements
From A52499
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. The diagnosis code that justifies the need for these items must be included on the claim. CONTINUED MEDICAL NEED For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, unless continued coverage requirements are specified in the LCD, ongoing need for the lens(es) is assumed to be met. There is no requirement for further documentation of continued medical need as long as the beneficiary continues to meet the prosthetic devices benefit.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
Denial language in the policy
- If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary. Source: L33793
- If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Source: L33793
- In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary. Source: L33793
- All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary. Source: L33793
Get the signed answer via API
The signed answer is the receipt for this code on a date of service: the rule that was in force, with a hash you can replay. The call needs an API key. The source archive and as-of resolution are public.
curl -H "X-API-Key: $VERZI_API_KEY" \
"https://api.verzi.health/v1/rules/warrant?hcpcs=V2020&as_of=2024-01-15&npi=1234567890&state=UT"Questions about this code
Which LCD lists V2020?
The current DME MAC LCD L33793, Refractive Lenses, version 20, effective 10/01/2020.
Which National Coverage Determination applies to V2020?
NCD 80.4, Hydrophilic Contact Lenses, version 1, is the current national document related from the LCD.
What denial language does CMS publish for V2020?
If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
How do I get a signed answer for V2020?
Request a free API key and call the signed-answer endpoint with the HCPCS code, a date of service, the supplier NPI, and a state. The response is a receipt for the published rule on that date, not a guarantee of payment.