Our Services
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Insurance Coverage
General Medicare Guidelines for Eye Prostheses
We provide:
- Custom Designed Artificial Eyes including
- Replacements (standard fitting)
- Sclera Shell
- Conformers
Modification of existing prosthetic eyes including:
- Enlargements, reductions and color adjustments
- Cleaning and resurfacing of prosthetic eyes
Working with special needs patients such as;
- Those in nursing home care
- Those in the hospital
- Children of all ages
Replacements are recommended every 3-5 years for therapeutic reasons. Body fluids absorb into the prosthesis, weight loss or gain, affecting socket size; etc. The prosthetic should be cleaned, polished and glazed every 6 months to enhance it.
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Professional Fees
Referred patients frequently inquire about the cost for fitting and making an ocular prosthesis. In the United States there is an established range of fees from $1,350 to $2,500 for an ocular prosthesis. Sclera shell prostheses fees range from $1,500 to $2,800.
The fee may be more or less depending on where you live, and the work required. It should be understood that it is very difficult for any ocularist to quote a fee without first examining the patient.
The majority of ocularist offers the initial consultation visit without obligation and the charges will be explained at the time of your consultation visit.
If insurance coverage is available, most ocularist offices will assist you in every possible way to obtain full benefits of your policy. However, it should be noted that the patient, or in the case of children, a parent or guardian is always responsible for payment. In most cases it is necessary to obtain a referral from your doctor before work can begin.
Fairbanks Ocular Prosthetics does not have financing available for our services, but for the convenience of our patients, we accept most major credit cards as a form of payment. We can also help with accommodations in Nashville if you visit us from out of town for your fitting.
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Insurance Coverage
Medicare coverage: Prosthetic eyes and related services are a covered procedure under Medicare and Medicaid guidelines. Prior to beginning your fitting, a request from your doctor is required. This request can be in the form of a written prescription from your doctor. Our office has a pre-written form letter which we can send to doctor via fax requesting his/her referral. Medicare has strict guidelines regarding the fitting and replacement of ocular prostheses.
Medicare pays 80% of their allowed amount based on what part of the country you live. If you have a Medicare supplement, in most cases it pays the additional 20%. This office requires Medicare patients to cover their professional service at the time they are provided. Our fee is due at the time the ocular prosthetic is delivered.
Other Insurance Carriers: Most insurance will pay at least a portion of the fitting and supply fees for your artificial eye. Prosthetic devices are categorized by insurance companies as Durable Medical Equipment, or DME. As such, most insurers will pay 80 percent of their company’s allowed amount. This allowed amount varies from company to company. Unfortunately, most companies will not divulge what their allowed amounts for the service will be.
Most ocularist offices will help you to secure the highest level of coverage for each case, but don't assume the complete cost will be covered by your insurance.
Coverage issues can usually be obtained by calling the Member Services telephone number listed on your insurance card.
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General Medicare Guidelines for Eye Prostheses
SUBJECT:
HCPCS CODE: BENEFIT CATEGORY: Ocular Prosthetic Device
V2623 - PROSTHETIC EYE, PLASTIC CUSTOM AFTER REMOVAL
An order for the initial eye prosthesis which is signed and dated by the ordering physician must be kept on file by the supplier. The physician's records must contain information which supports the medical necessity of the item ordered. The ocularist documentation of the necessity for replacement prosthesis is appropriate documentation for that claim if the replacement is necessitated by other than medical reasons such as an accidental loss.
Replacement eye prostheses are covered every five (5) years with exceptions allowed when documentation supports medical necessity for more frequent replacement.
V2624 - POLISHING/RESURFACING OF OCULAR PROSTHESIS
Polishing and resurfacing (V2624) is covered on a twice yearly basis. If the patient requires more frequent polishing, the expense will be the responsibility of the patient.
V2625 - ENLARGEMENT OF OCULAR PROSTHESIS
V2626 - REDUCTION OF OCULAR PROSTHESIS
One enlargement (V2625) or reduction (V2626) of the prosthesis within five years of the fitting date is covered without documentation.
Additional enlargements or reductions are rarely medically necessary and are therefore covered only when accompanied by documentation which supports medical necessity.
V2627 - SCLERA COVER SHELL OVER SHRUNKEN EYES
An eye prosthesis is covered for a patient with absence or shrinkage of an eye due to birth defect, trauma or surgical removal.
V2628 - FABRICATION AND FITTING OF OCULAR CONFORMER
Custom conformers request by a physician with a prescription are covered by Medicare under (V2628)
V2629 - PROSTHETIC EYE, OTHER TYPE
This code will be used for other ocular prosthetic devices not covered by (V2623) through (V2628). All claims under this code must be by report and requested by a physician.
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