Cal. Code Regs. tit. 22 § 51317

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 51317 - Eyeglasses, Contact Lenses, Low Vision Aids, Prosthetic Eyes and Other Eye Appliances

(a) Eye appliances are covered on the written prescription of a physician or optometrist, subject to the provisions of this section.

(1) Providers shall make a reasonable effort to ascertain and record the age, source and characteristics of the beneficiary's most recent ophthalmic correction. A review of the provider's prior records and questioning the beneficiary concerning prior ophthalmic corrections will satisfy this requirement.

(2) Lost, broken or significantly damaged eye appliances may not be replaced unless the beneficiary or beneficiary's representative supplies the provider with a signed statement outlining the circumstances of the loss or destruction and the steps taken to recover the lost item, and certifying that the loss, breakage or damage was beyond the beneficiary's control. Providers shall not be held responsible for inaccurate statements by beneficiaries. A provider may certify that specific items require replacement due to normal wear and tear or aging and that no abuse is evident.

(3) Repair or replacement of ophthalmic frames for lenses that do not conflict with the criteria in (c)(1), (2), (4)(A) and (B) is covered without a prescription.

(4) The following are not covered:

(A) Eyeglasses used primarily for protective, cosmetic, occupational or avocational purposes.

(B) Eyeglasses prescribed for other than the correction of refractive errors or binocularity anomalies.

(C) Double segment bifocal or no-line multifocal lenses.

(D) Multifocal contact lenses.

(b) Eye appliances to supplement an existing eye appliance, regardless of the source of the existing appliance, are limited to the following:

(1) Two pairs of single vision eyeglasses, one for distance vision and one for near vision, in lieu of multifocal eyeglasses when there are indications that multifocal lenses cannot be worn satisfactorily. When two pairs of single vision lenses are thus supplied, both shall meet the requirements of (c)(1) and, when applicable, (c)(3) and (c)(4). Except for those that qualify as a low vision aid, single vision eyeglasses to supplement multifocals are not a program benefit.

(2) Low vision aids, including single vision eyeglasses prescribed as a low vision aid.

(3) Ptosis crutches, occluders, bandage contact lenses, prosthetic eyes and prostheic scleral shells.

(4) Overcorrection single vision or bifocal eyeglasses for concurrent use with contact lenses. Prescription eyeglasses for alternative use by a person who has and is able to wear contact lenses are not covered. Contact lenses shall not subsequently be covered after a patient has been provided prescription eyeglasses because the patient could not wear contact lenses.

(c) Prescription eyeglass lenses conforming to American National Standard Requirements for First Quality Prescription Lenses Z80.11972 are covered if the prescription is for:

(1) Single vision lenses and specifies at least one of the following:

(A) Power in at least one meridian of either lens of 0.75 diopters or more.

(B) Astigmatic correction of either eye of 0.75 diopters or more.

(C) Total differential prismatic correction of 3/4 or more prism diopters in the vertical meridian.

(D) Total differential prismatic correction of one and one-half or more prism diopters in the horizontal meridian.

(E) Power in any meridian that differs from the corresponding meridian of the lens for the other eye by 0.75 diopters or more.

(2) Multifocal lenses with an add of at least 0.75 diopters.

(3) Replacement lenses which meet the criteria in (1) or (2) and also one or more of the following:

(A) The power is changed at least 0.50 diopters in any corresponding meridian.

(B) The cylinder axis is changed 20 or more degrees for a 0.50-0.62 diopter cylinder in the old or new correction, 15 or more degrees for a 0.75-0.87 diopter cylinder, 10 or more degrees for a 1.00-1.87 diopter cylinder or 5 or more degrees for a 2.00 diopter or stronger cylinder. Change in axis in cylinders of 0.12-0.37 diopters, as the sole reason for change, is not covered.

(C) The prismatic differential correction is changed at least 3/4 prism diopters in the vertical meridian or at least one and one-half prism diopters in the horizontal meridian.

(D) The previous lens is lost, broken or marred to a degree significantly interfering with vision or eye safety. A certificate or statement as specified in paragraph (a)(2) is required.

(E) The frame must be replaced because a different size or shape is necessary.

(4) Absorptive lenses which reduce the amount of light energy reaching the eye, or selectively restrict the passage of specific parts of the light spectrum, meet the criteria for coverage under (1), (2), or (3), and are provided under any of the following conditions:

(A) when eye pathology that is aggravated by exposure to this light exists,

(B) when the normal eye protective system that guards against this light is compromised, or

(C) when chronic pathological conditions that are intensified by exposure to this light energy are present.

All absorptive lenses provided under the program shall be identified by manufacturer and by trade name, and be represented by established and published transmission charts that confirm the eye protection objective of the lens.

(5) Trifocal lenses which meet the criteria in (1), (2) or (3), but only for beneficiaries who are currently wearing trifocals.

(6) A balance lens, when the corrected acuity for the poorer eye is not better than 0.10 decimal notation, 20/200 Snellen or equivalent at specified distances. Coverage for the poorer eye is limited to a single vision balance lens unless a prescription lens is medically justified. Multifocal balance lenses are not covered.

(d) Eyeglass frames conforming to American National Standard Requirements for Dress Ophthalmic Frames Z80.5--1979 are covered when the beneficiary does not possess a frame suitable for continued use. Replacement eyeglass frames are not covered if a previous frame can be made suitable for continued use by adjustment, repair or replacement of a broken front or temples. Repairs and parts replacement are covered.

(1) Replacement of frames lost, stolen or destroyed in circumstances beyond the beneficiary's control is covered. A certificate or statement as specified in paragraph (a)(2) is required. Replacement of frames deliberately destroyed, abused or discarded by the beneficiary is not covered. Replacement of frames for reasons other than lost, theft or destruction in circumstances beyond the beneficiary's control may be covered when the provider submits a statement as specified in paragraph (a)(2) explaining why the prior frame cannot continue in use.

(2) Replacement of frames within two years is limited to the same model whenever feasible.

(3) Frames are not covered for use with lenses weaker than the minimums specified for an original prescription, as defined in (c)(1) and (2) in this section.

(4) Frames shall be sturdy and of good quality with the manufacturer's or American distributor's name or identification clearly stamped on the frame. Only frames which the provider also supplies to the general public shall be provided to Medi-Cal patients. Discontinued or closeout frames are not covered. The provider shall allow the patient to try on and choose from an adequate selection of frame styles, colors and sizes.

(e) Contact lenses, limited to lenses for which the federal Food and Drug Administration has given approval of the lenses and the applications and hard lenses conforming to American National Standard Requirements for First Quality Contact Lenses Z80.2--1972 are covered as follows:

(1) Following prior authorization for:

(A) Extended wear contact lenses which require more professional postdispensing monitoring than lenses designed for daily removal and disposable prescription contact lenses designed for short-term wear and frequent replacement. Authorization may be granted upon verification that other lenses cannot be used and there is reasonable assurance the patient can use the specialized lenses.

(B) Contact lenses when chronic pathology or deformity of the nose, skin or ears precludes the wearing of eyeglasses.

(C) Contact lenses for a diagnosis of aniseikonia when supported by clinical data.

(2) Without prior authorization for:

(A) A diagnosis of aphakia or keratoconus when contact lenses other than extended wear contact lenses are fitted. If extended wear contact lenses are to be provided, prior authorization is required.

(B) When eyeglasses are contraindicated due to chronic corneal or conjunctival pathology or deformity other than corneal astigmatism; when contact lenses other than extended wear contact lenses are fitted. If extended wear contact lenses are to be provided, prior authorization is required.

(C) Therapeutic bandage lenses prescribed by a physician for a diagnosis approved by the federal Food and Drug Administration for those lenses, when fitted by a physician or by either a dispensing optician or an optometrist under the direct supervision of a physician.

(f) Low vision optical aids, excluding electronic devices, are covered when visual function is markedly enhanced and all the following conditions are satisfied:

(1) Visual acuity in the better eye when optimal correction with a prescription eyeglass lens or contact lens is equal to or poorer than 0.30 decimal notation, 20/60 Snellen, or equivalent at specified distances, or either visual field is limited to 10 degrees or less from the point of fixation in any direction.

(2) The condition causing the subnormal vision is chronic and cannot be relieved by medical or surgical intervention.

(3) The physical and mental condition of the patient is such that there is a reasonable expectation that the aid will be used to enhance the everyday functioning of the beneficiary.

(4) The aid prescribed or provided is the least costly type that will meet the needs of the patient.

(5) Prior authorization, when the amount claimed for payment of an aid is $100.00 or more, has been obtained from:

(A) The California Children Services, in accordance with Section 51013, when the beneficiary is under, or who is a candidate for, case management by that program.

(B) The Medi-Cal consultant for:

1. Low vision aids recommended by the Department of Rehabilitation in accordance with Section 51014.

2. All others.

(6) TARs for low vision aids shall include:

(A) The etiology, current status and prognosis of the visual defect.

(B) The visual acuity at far and at near, measured monocularly and binocularly with optimum spectacle or contact lens correction.

(C) The visual acuities using the aid.

(D) A copy of the detailed field study when the aid is designed to compensate for a field defect.

(E) A description of the aid, including cost, model number and name of distributor or manufacturer.

(F) A statement of the amount of professional time expended in fitting the aid, excluding diagnostic and follow-up time associated with the fitting and postfitting supervision of the patient by a medical or optometric provider.

(g) Prosthetic Eyes. A written prescription by a physician or optometrist is required for the provision of prosthetic eyes.

(1) The claim for reimbursement shall include the following:

(A) Explanation of the need for a prosthetic eye.

(B) Prior prosthetic eye history.

(C) Description of and justification for other than a precast prosthesis.

(2) Prosthetic eyes may be replaced:

(A) To accommodate changes resulting from orbital development in persons under 18 years of age.

(B) When necessary to prevent a significant disability.

(C) When the prior prosthesis was lost or destroyed due to circumstances beyond the beneficiary's control.

(D) When the prior prosthesis can no longer be rehabilitated.

(3) Repair of a prosthetic eye may be covered as an unlisted eye appliance procedure.

Cal. Code Regs. Tit. 22, § 51317

1. Amendment of subsections (c)(2) and (c)(4) filed 6-24-83 as an emergency; effective upon filing (Register 83, No. 26). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 10-22-83. For prior history, see Register 83, No. 26.
2. Repealer and new section filed 7-8-83; effective thirtieth day thereafter (Register 83, No. 30).
3. Certificate of Compliance as to 6-24-83 order transmitted to OAL 10-21-83 and filed 11-23-83 (Register 83, No. 48).
4. Amendment of subsection (g) filed 8-23-85; effective thirtieth day thereafter (Register 85, No. 36).
5. Amendment of subsections (c)(1)(D), (c)(3)(C) and (c)(4)(A) filed 9-30-85 as an emergency; effective upon filing (Register 85, No. 40). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-28-86.
6. Certificate of Compliance transmitted to OAL 1-8-86 and filed 2-6-86 (Register 86, No. 6).
7. Amendment of subsections (c)(4) and (d)(3) filed 11-14-86; effective thirtieth day thereafter (Register 86, No. 46).

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14110.5, 14132, 14133 and 14133.1, Welfare and Institutions Code; and Statutes of 1985, Chapter 111, Item 4260-101-001, Provision 21.