NCTracks
Attention: Optical Providers Reminder: Criteria for Polycarbonate Eyeglass Lenses
When requesting prior approval for polycarbonate eyeglass lenses, the beneficiary must meet at least one of the following criteria:
- Requires single vision or bifocal + or - 5.00 diopters or higher in one meridian (sphere, cylinder, combination of sphere and cylinder, or prism);
- Is blind or legally blind in one eye, with correction in accordance with guidelines (found in Subsection 5.6 of the clinical coverage policy) for the sighted eye;
- Is aged birth through 6 years of age;
- Has Medical/physical conditions that result in frequent trauma or falls.
For conditions requiring polycarbonate eyeglass lenses beyond the criteria listed above, submit documentation of medical necessity with the prior approval request. Each prior approval request will be reviewed for medical necessity on an individual basis. Refer to Clinical Coverage Policy No. 6A, section 5.6.3, for additional information.