LCD L33793 Refractive Lenses: Medicare coverage…

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L33793
Contract	Contractor	Type	States
19003	Noridian Healthcare Solutions, LLC	DME MAC	AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY
18003	CGS Administrators, LLC	DME MAC	AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV
17013	CGS Administrators, LLC	DME MAC	IL IN KY MI MN OH WI
16013	Noridian Healthcare Solutions, LLC	DME MAC	CT DC DE MA MD ME NH NJ NY PA RI VT

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Article A52499 (Refractive Lenses - Policy Article) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A52499: Refractive Lenses - Policy Article (Article, effective 2020-10-01)

Covered ICD-10-CM codes: 6; 1 group
Non-covered ICD-10-CM codes: 0
Procedure codes listed: 0
Full article: cms.gov record

First 6 covered ICD-10-CM codes in A52499
ICD-10-CM	Description (FY2027)
H27.00	—
H27.01	—
H27.02	—
H27.03	—
Q12.3	—
Z96.1	—

Procedure codes named in the LCD

V2020 (Frames, Purchases), V2025 (Deluxe Frame), V2100 (Sphere, Single Vision, Plano To Plus Or Minus 4.00, Per Lens), V2101 (Sphere, Single Vision, Plus Or Minus 4.12 To Plus Or Minus 7.00D, Per Lens), V2102 (Sphere, Single Vision, Plus Or Minus 7.12 To Plus Or Minus 20.00D, Per Lens), V2103 (Spherocylinder, Single Vision, Plano To Plus Or Minus 4.00D Sphere, .12 To 2.00D Cylinder, Per Lens), V2104 (Spherocylinder, Single Vision, Plano To Plus Or Minus 4.00D Sphere, 2.12 To 4.00D Cylinder, Per Lens), V2105 (Spherocylinder, Single Vision, Plano To Plus Or Minus 4.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2106 (Spherocylinder, Single Vision, Plano To Plus Or Minus 4.00D Sphere, Over 6.00D Cylinder, Per Lens), V2107 (Spherocylinder, Single Vision, Plus Or Minus 4.25 To Plus Or Minus 7.00 Sphere, .12 To 2.00D Cylinder, Per Lens), V2108 (Spherocylinder, Single Vision, Plus Or Minus 4.25D To Plus Or Minus 7.00D Sphere, 2.12 To 4.00D Cylinder, Per Lens), V2109 (Spherocylinder, Single Vision, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2110 (Spherocylinder, Single Vision, Plus Or Minus 4.25 To 7.00D Sphere, Over 6.00D Cylinder, Per Lens), V2111 (Spherocylinder, Single Vision, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, .25 To 2.25D Cylinder, Per Lens), V2112 (Spherocylinder, Single Vision, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 2.25D To 4.00D Cylinder, Per Lens), V2113 (Spherocylinder, Single Vision, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2114 (Spherocylinder, Single Vision, Sphere Over Plus Or Minus 12.00D, Per Lens), V2115 (Lenticular, (Myodisc), Per Lens, Single Vision), V2118 (Aniseikonic Lens, Single Vision), V2121 (Lenticular Lens, Per Lens, Single), V2199 (Not Otherwise Classified, Single Vision Lens), V2200 (Sphere, Bifocal, Plano To Plus Or Minus 4.00D, Per Lens), V2201 (Sphere, Bifocal, Plus Or Minus 4.12 To Plus Or Minus 7.00D, Per Lens), V2202 (Sphere, Bifocal, Plus Or Minus 7.12 To Plus Or Minus 20.00D, Per Lens), V2203 (Spherocylinder, Bifocal, Plano To Plus Or Minus 4.00D Sphere, .12 To 2.00D Cylinder, Per Lens), V2204 (Spherocylinder, Bifocal, Plano To Plus Or Minus 4.00D Sphere, 2.12 To 4.00D Cylinder, Per Lens), V2205 (Spherocylinder, Bifocal, Plano To Plus Or Minus 4.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2206 (Spherocylinder, Bifocal, Plano To Plus Or Minus 4.00D Sphere, Over 6.00D Cylinder, Per Lens), V2207 (Spherocylinder, Bifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere,.12 To 2.00D Cylinder, Per Lens), V2208 (Spherocylinder, Bifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, 2.12 To 4.00D Cylinder, Per Lens), V2209 (Spherocylinder, Bifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2210 (Spherocylinder, Bifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, Over 6.00D Cylinder, Per Lens), V2211 (Spherocylinder, Bifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, .25 To 2.25D Cylinder, Per Lens), V2212 (Spherocylinder, Bifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 2.25 To 4.00D Cylinder, Per Lens), V2213 (Spherocylinder, Bifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2214 (Spherocylinder, Bifocal, Sphere Over Plus Or Minus 12.00D, Per Lens), V2215 (Lenticular (Myodisc), Per Lens, Bifocal), V2218 (Aniseikonic, Per Lens, Bifocal), V2219 (Bifocal Seg Width Over 28 Mm), V2220 (Bifocal Add Over 3.25D), V2221 (Lenticular Lens, Per Lens, Bifocal), V2299 (Specialty Bifocal (By Report)), V2300 (Sphere, Trifocal, Plano To Plus Or Minus 4.00D, Per Lens), V2301 (Sphere, Trifocal, Plus Or Minus 4.12 To Plus Or Minus 7.00D, Per Lens), V2302 (Sphere, Trifocal, Plus Or Minus 7.12 To Plus Or Minus 20.00, Per Lens), V2303 (Spherocylinder, Trifocal, Plano To Plus Or Minus 4.00D Sphere, .12-2.00D Cylinder, Per Lens), V2304 (Spherocylinder, Trifocal, Plano To Plus Or Minus 4.00D Sphere, 2.25-4.00D Cylinder, Per Lens), V2305 (Spherocylinder, Trifocal, Plano To Plus Or Minus 4.00D Sphere, 4.25 To 6.00 Cylinder, Per Lens), V2306 (Spherocylinder, Trifocal, Plano To Plus Or Minus 4.00D Sphere, Over 6.00D Cylinder, Per Lens), V2307 (Spherocylinder, Trifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, .12 To 2.00D Cylinder, Per Lens), V2308 (Spherocylinder, Trifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, 2.12 To 4.00D Cylinder, Per Lens), V2309 (Spherocylinder, Trifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2310 (Spherocylinder, Trifocal, Plus Or Minus 4.25 To Plus Or Minus 7.00D Sphere, Over 6.00D Cylinder, Per Lens), V2311 (Spherocylinder, Trifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, .25 To 2.25D Cylinder, Per Lens), V2312 (Spherocylinder, Trifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 2.25 To 4.00D Cylinder, Per Lens), V2313 (Spherocylinder, Trifocal, Plus Or Minus 7.25 To Plus Or Minus 12.00D Sphere, 4.25 To 6.00D Cylinder, Per Lens), V2314 (Spherocylinder, Trifocal, Sphere Over Plus Or Minus 12.00D, Per Lens), V2315 (Lenticular, (Myodisc), Per Lens, Trifocal), V2318 (Aniseikonic Lens, Trifocal), V2319 (Trifocal Seg Width Over 28 Mm), V2320 (Trifocal Add Over 3.25D), V2321 (Lenticular Lens, Per Lens, Trifocal), V2399 (Specialty Trifocal (By Report)), V2410 (Variable Asphericity Lens, Single Vision, Full Field, Glass Or Plastic, Per Lens), V2430 (Variable Asphericity Lens, Bifocal, Full Field, Glass Or Plastic, Per Lens), V2499 (Variable Sphericity Lens, Other Type), V2500 (Contact Lens, Pmma, Spherical, Per Lens), V2501 (Contact Lens, Pmma, Toric Or Prism Ballast, Per Lens), V2502 (Contact Lens, Pmma, Bifocal, Per Lens), V2503 (Contact Lens, Pmma, Color Vision Deficiency, Per Lens), V2510 (Contact Lens, Gas Permeable, Spherical, Per Lens), V2511 (Contact Lens, Gas Permeable, Toric, Prism Ballast, Per Lens), V2512 (Contact Lens, Gas Permeable, Bifocal, Per Lens), V2513 (Contact Lens, Gas Permeable, Extended Wear, Per Lens), V2520 (Contact Lens, Hydrophilic, Spherical, Per Lens), V2521 (Contact Lens, Hydrophilic, Toric, Or Prism Ballast, Per Lens), V2522 (Contact Lens, Hydrophilic, Bifocal, Per Lens), V2523 (Contact Lens, Hydrophilic, Extended Wear, Per Lens), V2524 (Contact Lens, Hydrophilic, Spherical, Photochromic Additive, Per Lens), V2530 (Contact Lens, Scleral, Gas Impermeable, Per Lens (For Contact Lens Modification, See 92325)), V2531 (Contact Lens, Scleral, Gas Permeable, Per Lens (For Contact Lens Modification, See 92325)), V2599 (Contact Lens, Other Type), V2600 (Hand Held Low Vision Aids And Other Nonspectacle Mounted Aids), V2610 (Single Lens Spectacle Mounted Low Vision Aids), V2615 (Telescopic And Other Compound Lens System, Including Distance Vision Telescopic, Near Vision Telescopes And Compound Microscopic Lens System), V2700 (Balance Lens, Per Lens), V2702 (Deluxe Lens Feature), V2710 (Slab Off Prism, Glass Or Plastic, Per Lens), V2715 (Prism, Per Lens), V2718 (Press-On Lens, Fresnell Prism, Per Lens), V2730 (Special Base Curve, Glass Or Plastic, Per Lens), V2744 (Tint, Photochromatic, Per Lens), V2745 (Addition To Lens; Tint, Any Color, Solid, Gradient Or Equal, Excludes Photochromatic, Any Lens Material, Per Lens), V2750 (Anti-Reflective Coating, Per Lens), V2755 (U-V Lens, Per Lens), V2756 (Eye Glass Case), V2760 (Scratch Resistant Coating, Per Lens), V2761 (Mirror Coating, Any Type, Solid, Gradient Or Equal, Any Lens Material, Per Lens), V2762 (Polarization, Any Lens Material, Per Lens), V2770 (Occluder Lens, Per Lens), V2780 (Oversize Lens, Per Lens), V2781 (Progressive Lens, Per Lens), V2782 (Lens, Index 1.54 To 1.65 Plastic Or 1.60 To 1.79 Glass, Excludes Polycarbonate, Per Lens), V2783 (Lens, Index Greater Than Or Equal To 1.66 Plastic Or Greater Than Or Equal To 1.80 Glass, Excludes Polycarbonate, Per Lens), V2784 (Lens, Polycarbonate Or Equal, Any Index, Per Lens), V2786 (Specialty Occupational Multifocal Lens, Per Lens), V2797 (Vision Supply, Accessory And/Or Service Component Of Another Hcpcs Vision Code), V2799 (Vision Item Or Service, Miscellaneous).

Coverage indications, limitations and medical necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Refer to the Supplier Manual for additional information on documentation requirements.

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Statutory coverage criteria for refractive lenses are specified in the related Policy Article.

For beneficiaries who are aphakic (i.e., who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens), the following lenses or combinations of lenses are covered when determined to be medically necessary:

• Bifocal lenses in frames; or

• Lenses in frames for far vision and lenses in frames for near vision; or

• When a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), payment will be made for the contact lens(es), and lens(es) in frames for near vision to be worn at the same time as the contact lens(es) and lenses in frames to be worn when the contacts have been removed.

For beneficiaries who are pseudophakic (i.e., those who have an IOL), refer to the Policy Article for information about coverage of the initial pair of lenses.

For aphakic beneficiaries (i.e., those who do not have an IOL), replacement lenses are covered when they are medically necessary. Refer to the Policy Article for information about noncoverage of replacement lenses for pseudophakic beneficiaries.

Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner. When these features are provided as a beneficiary preference item and are billed with an EY modifier (see LCD-related Standard Documentation Requirements Article), they will be denied as not reasonable and necessary.

UV protection is considered reasonable and necessary following cataract extraction; therefore, additional medical necessity justification by the treating practitioner beyond inclusion on the order is not necessary.

The addition of UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary. Additional information regarding the coding and billing of UV coating (V2755) on lenses with UV protective properties inherent in the material may be found in the related Policy Article.

Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to an aphakic beneficiary, will be denied as not reasonable and necessary.

Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are covered. Claims for code V2784 that do not meet this coverage criterion will be denied as not reasonable and necessary.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of evidence (opening)

N/A

the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective: 2015-10-01
Current revision effective: 2020-10-01
Last reviewed by the contractor: 2019-01-08
MCD version: 20
Derived from: L27037

The contractor lists one National Coverage Determination as related: NCD 80.4 Hydrophilic Contact Lenses. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

Other related documents: A55426 (Article).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.

Frequently asked questions

What does LCD L33793 cover?

Statutory coverage criteria for refractive lenses are specified in the related Policy Article. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L33793 apply to?

Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L33793?

The companion article article A52499 lists 6 ICD-10-CM codes in 1 group that support medical necessity; the first 6 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L33793?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Medicare Coverage Database, current LCD export
Version MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
Medicare Coverage Database, current Billing and Coding Articles export
Version MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
ICD-10-CM FY2027 code descriptions
Version FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.

LCD L33793: Refractive Lenses