Iowa Admin. Code r. 441-78.6 - Optometrists
Payment will be approved for medically necessary services and supplies provided by the optometrist within the scope of practice of optometry and the limitations of state law, subject to the following limitations and exclusions. Covered optometric services include a professional component and materials.
(1)
Payable
professional services. Payable professional services are:
a. Eye examinations. The coverage of eye
examinations depends on the purpose of the examination. Services are covered if
the examination is the result of a complaint or symptom of an eye disease or
injury. Routine eye examinations are covered once in a 12-month period. These
services are rendered in the optometrist's office or clinic, the home, a
nursing facility, or other appropriate setting. Payment for mileage shall be
subject to the same approval and payment criteria as those in effect for
Medicare Part B. The following levels of service are recognized for optometric
examinations:
(1) Intermediate examination. A
level of optometric or ophthalmological services pertaining to medical
examination and evaluation, with initiation or continuation of a diagnostic and
treatment program.
(2)
Comprehensive examination. A level of optometric or ophthalmological services
pertaining to medical examination and evaluation, with initiation or
continuation of a diagnostic and treatment program, and a general evaluation of
the complete visual system.
b. Medical services. Payment will be approved
for medically necessary services and supplies within the scope of practice of
the optometrist, including services rendered in the optometrist's office or
clinic, the home, a nursing facility, or other appropriate setting. Payment for
mileage shall be subject to the same approval and payment criteria as those in
effect for Medicare Part B.
c.
Auxiliary procedures. The following auxiliary procedures and special tests are
payable when performed by an optometrist. Auxiliary procedures and special
tests are reimbursed as a separate procedure only when warranted by case
history or diagnosis.
(1) Serial tonometry.
Single tonometry is part of the intermediate and comprehensive exams and is not
payable as a separate procedure as is serial tonometry.
(2) Gonioscopy.
(3) Extended ophthalmoscopy. Routine
ophthalmoscopy is part of the intermediate and comprehensive examination and is
not payable as a separate procedure. Generally, extended ophthalmoscopy is
considered to be part of the comprehensive examination and, if performed in
conjunction with that level of service, is not payable as a separate
procedure.
(4) Visual fields. Gross
visual field testing is part of general optometric services and is not reported
separately.
(5) External
photography.
(6) Fundus
photography.
(7) Retinal integrity
evaluation with a three-mirror lens.
d. Single vision and multifocal spectacle
lens service, verification and subsequent service. When lenses are necessary,
the following enumerated professional and technical optometric services are to
be provided:
(1) When spectacle lenses are
necessary, the following enumerated professional and technical optometric
services are to be provided:
1. Ordering of
corrective lenses.
2. Verification
of lenses after fabrication.
3.
Adjustment and alignment of completed lens order.
(2) New spectacle lenses are subject to the
following limitations:
1. Up to three times
for children up to one year of age.
2. Up to four times per year for children one
through three years of age.
3. Once
every 12 months for children four through seven years of age.
4. Once every 24 months after eight years of
age when there is a change in the prescription.
(3) Spectacle lenses made from polycarbonate
or equivalent material are allowed for:
1.
Children through seven years of age.
2. Members with vision in only one
eye.
3. Members with a
diagnosis-related illness or disability where regular lenses would pose a
safety risk.
e. Rescinded IAB 4/3/02, effective 6/1/02.
f. Frame service.
(1) When a new frame is necessary, the
following enumerated professional and technical optometric services are to be
provided:
1. Selection and styling.
2. Sizing and measurements.
3. Fitting and adjustment.
4. Readjustment and servicing.
(2) New frames are subject to the
following limitations:
1. One frame every six
months is allowed for children through three years of age.
2. One frame every 12 months is allowed for
children four through seven years of age.
3. When there is a covered lens change and
the new lenses cannot be accommodated by the current frame.
(3) Safety frames are allowed for:
1. Children through seven years of
age.
2. Members with a
diagnosis-related disability or illness where regular frames would pose a
safety risk or result in frequent breakage.
g. Rescinded IAB 4/3/02, effective
6/1/02.
h. Repairs or replacement
of frames, lenses or component parts. Payment shall be made for service in
addition to materials. The service fee shall not exceed the dispensing fee for
a replacement frame. Payment shall be made for replacement of glasses when the
original glasses have been lost or damaged beyond repair. Replacement of lost
or damaged glasses is limited to one pair of frames and two lenses once every
12 months for adults aged 21 and over, except for people with a mental or
physical disability.
i. Contact
lenses. Payment shall be made for documented keratoconus, aphakia, high myopia,
anisometropia, trauma, severe ocular surface disease, irregular astigmatism,
for treatment of acute or chronic eye disease, or when the member's vision
cannot be adequately corrected with spectacle lenses. Contact lenses are
subject to the following limitations:
(1) Up
to 16 gas permeable contact lenses are allowed for children up to one year of
age.
(2) Up to 8 gas permeable
contact lenses are allowed every 12 months for children one through three years
of age.
(3) Up to 6 gas permeable
contact lenses are allowed every 12 months for children four through seven
years of age.
(4) Two gas permeable
contact lenses are allowed every 24 months for members eight years of age or
older.
(5) Soft contact lenses and
replacements are allowed when medically necessary.
(2)
Ophthalmic
materials. Ophthalmic materials which are provided in connection with
any of the foregoing professional optometric services shall provide adequate
vision as determined by the optometrist and meet the following standards:
a. Corrected curve lenses, unless clinically
contraindicated.
b. Standard
plastic, plastic and metal combination, or metal frames.
c. Prescription standards according to the
American National Standards Institute (ANSI) standards and tolerance.
(3)
Reimbursement. The reimbursement for allowed ophthalmic
material is subject to a fee schedule established by the department or to
actual laboratory cost as evidenced by an attached invoice. Reimbursement for
rose tint is included in the fee for the lenses.
a. Materials payable by fee schedule are:
(1) Spectacle lenses, single vision and
multifocal.
(2) Frames.
(3) Case for glasses.
b. Materials payable at actual laboratory
cost as evidenced by an attached invoice are:
(1) Contact lenses.
(2) Schroeder shield.
(3) Ptosis crutch.
(4) Safety frames.
(5) Subnormal visual aids.
(6) Photochromatic lenses.
(4)
Prior
authorization. Prior authorization is required for the following:
a. A second lens correction within a 24-month
period for members eight years of age and older. Approval shall be given when
the member's vision has at least a five-tenths diopter of change in sphere or
cylinder or ten-degree change in axis in either eye.
b. Visual therapy may be authorized when
warranted by case history or diagnosis for a period of time not greater than 90
days. Should continued therapy be warranted, the prior approval process shall
be reaccomplished, accompanied by a report showing satisfactory progress.
Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy
is not covered when provided by opticians.
c. Subnormal visual aids where near visual
acuity is at or better than 20/100 at 16 inches, 2M print. Prior authorization
is not required if near visual acuity as described above is less than 20/100.
Subnormal visual aids include, but are not limited to, hand magnifiers, loupes,
telescopic spectacles, or reverse Galilean telescope systems. Payment shall be
actual laboratory cost as evidenced by an attached invoice.
d. Approval for photochromatic tint shall be
given when the member has a documented medical condition that causes
photosensitivity and less costly alternatives are inadequate.
e. Approval for press-on prisms shall be
granted for members whose vision cannot be adequately corrected with other
covered prisms.
(Cross reference 78.28(4))
(5)Noncovered services.
Noncovered services include, but are not limited to, the following services:
a. Glasses with cosmetic gradient tint lenses
or other eyewear for cosmetic purposes.
b. Glasses for occupational eye
safety.
c. A second pair of glasses
or spare glasses.
d. Cosmetic
surgery and experimental medical and surgical procedures.
e. Sunglasses.
f. Progressive bifocal or trifocal
lenses.
(6)
Therapeutically certified optometrists. Rescinded IAB 9/5/12,
effective 11/1/12.
This rule is intended to implement Iowa Code section 249A.4.
Notes
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