1. (1) Indications and coverage:

   1. (a) An eye prosthesis is indicated for a client (adult or child) with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal;
   2. (b) For clients under age 21, the prescribing practitioner shall determine and document medical appropriateness of the eye prosthesis and related services;

   3. (c) For clients age 21 and older, coverage is limited as follows:

      1. (A) Polishing and resurfacing will be allowed on a twice per year basis;
      2. (B) Replacement is covered every five years if documentation supports medical appropriateness. An exception to this limitation is allowed when clinical documentation supports medical appropriateness for more frequent replacement;
      3. (C) One enlargement (V2625) or reduction (V2626) of the prosthesis is covered. Additional enlargements or reductions are rarely medically indicated and are therefore covered only when clinical documentation supports medical appropriateness.

2. (2) Documentation requirements:

   1. (a) An order for each item shall be signed and dated by the treating physician, kept on file by the supplier, and made available upon request;
   2. (b) Documentation of medical appropriateness that has been reviewed and signed by the prescribing practitioner shall be kept on file by the supplier and made available upon request;
   3. (c) When billing for an item or service at a greater frequency than allowed, there shall be documentation in the patient’s medical records that corroborates the order and supports the medical appropriateness of the items. This documentation shall be kept on file by the supplier and available upon request.

3. (3) Procedure Codes – Table 122-0640.

   [ED. NOTE: Tables referenced are available from the agency.]

   [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.]

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 25-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 11-2016, f. 2-24-16, cert. ef. 3-1-16
DMAP 60-2014, f. 10-3-14, cert. ef. 10-7-14
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 17-1996, f. & cert. ef. 8-1-96
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 13-1991, f. & cert. ef. 3-1-91