Indications and Limitations of Coverage and/or Medical Necessity
Iowa, Kansas and Nebraska
The states listed above have separate requirements for an expanded optometry license.
A. Services provided by the Optometrist will be covered if they are within the scope of practice as defined by state law and performed as defined by state law.
1. If the condition identified and diagnosed at a visit requires treatment, the optometrist must have the required certification to prescribe and monitor treatment, as defined in law and administrative rules.
B. Post-operative Care - The post-operative care following eye surgery may be performed or shared between the operating ophthalmologist and an optometrist.
Missouri
A. Missouri state law states that the practice of the optometry is the examination, diagnosis, treatment, and preventative care of the eye, adnexa, and vision. The practice includes, but is not limited to:
1. The examination of the eye, adnexa, and vision to determine the accommodative and refractive states, visual perception, conditions, and diseases;
2. The diagnosis and treatment of conditions or diseases of the eye, adnexa, and vision;
3. The performance of diagnostic procedures and ordering of laboratory and imaging tests for the diagnosis of vision and conditions and diseases of the eye and adnexa;
4. The prescription and administration of pharmaceutical agents, excluding injectable agents, for the purpose of examination, diagnosis, and treatment of vision and conditions or diseases of the eye and adnexa;
5. The removal of superficial foreign bodies from the eye or adnexa;
6. The employment of objective or subjective mechanical means to determine the accommodative or refractive states of the human eye;
7. The prescription or adaptation of lenses, prisms, devices, or ocular exercises to correct defects or abnormal conditions of the human eye or vision or to adjust the human eye to special conditions;
8. The prescription and fitting of ophthalmic or contact lenses and devices;
9. The prescription and administration of vision therapy; and
10. The prescription and administration of low vision care.
11. An optometrist may not perform surgery, including the use of lasers for treatment of any disease or condition or for the correction of refractive error.
12. Diagnostic pharmaceutical agents, topically applied pharmaceuticals used for the purpose of conducting an examination of the eye, adnexa, and vision;
13. Pharmaceutical agents, any diagnostic and therapeutic drug or combination of drugs that assist the diagnosis, prevention, treatment, or mitigation of abnormal conditions or symptoms of the human eye, adnexa, and vision;
14. Therapeutic pharmaceutical agents, those pharmaceuticals, excluding injectable agents, used for the treatment of conditions or diseases of the eye, adnexa, and vision;
15. Vision therapy, a treatment regiment to improve a patient's diagnosed visual dysfunctions, prevent the development of visual problems, or enhance visual performance to meet the defined needs of the patient.
CMS National Coverage Policy:
CMS Pub. BP 100-2 15 §30.4; 100.2 16 §90; CMS Pub. CP 100-4 12 §30.6.6, 40.1A, 40.1D, 40.2; 100-4 13 §10; 100-4 23 §10-10.1.7; MCM § 2020.25, 4125, 4822, 15021.1
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered to be medically reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body part.
Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and eyeglasses.
Title XVIII of the Social Security Act section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
42CFR410.32 Diagnostic tests may only be ordered by the treating physician (or other treating practitioners acting within the scope of their licenses and Medicare requirements) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician
1. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening diagnosis should be reported, and payment will be denied.
2. Medical records should be legible, contain the relevant history and physical findings conforming to the criteria stated in the "Indications and Limitations of Coverage" section of this policy, and must be made available to the Carrier on request.
3. When applicable, a copy of the therapeutic/expanded licensure Certification from the state should be filed with the WPS Provider Enrollment unit
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