Current through Register Vol. 24-18, September 15, 2024
Refer to chapter 182-544 WAC for vision-related hardware
coverage.
(1) The medicaid agency
covers eye examinations, refraction and fitting services. The agency pays for
these services without prior authorization as follows:
(a) Once every twenty-four months for
asymptomatic clients age twenty-one and older;
(b) Once every twelve months for asymptomatic
clients age twenty and younger; or
(c) Once every twelve months, regardless of
age, for asymptomatic clients of the division of developmental
disabilities.
(2) The
agency covers additional eye examinations and refraction services when:
(a) The provider is diagnosing or treating
the client for a medical condition that has symptoms of vision problems or
disease;
(b) The client is on
medication that affects vision; or
(c) An eye examination or refraction is
necessary due to lost or broken eyeglasses or contacts. In this case:
(i) No type of authorization is required for
clients age twenty or younger or for clients of the division of developmental
disabilities, regardless of age.
(ii) Providers must follow the agency's
expedited prior authorization process to receive payment for clients age
twenty-one or older. Providers must also document the following in the client's
file:
(A) The eyeglasses or contacts are lost
or broken; and
(B) The last
examination was at least eighteen months ago.
(3) The agency covers visual field
exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries.
Providers must document all of the following in the client's record:
(a) The extent of the testing;
(b) Why the testing was reasonable and
necessary for the client; and
(c)
The medical basis for the frequency of testing.
(4) The agency covers orthoptics and vision
training therapy. Providers must obtain prior authorization from the
agency.
(5) The agency covers
ocular prosthetics for clients when provided by any of the following:
(a) An ophthalmologist;
(b) An ocularist; or
(c) An optometrist who specializes in
prosthetics.
(6) The
agency covers cataract surgery, without prior authorization when the following
clinical criteria are met:
(a) Correctable
visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen
test chart; or
(b) One or more of
the following conditions:
(i) Dislocated or
subluxated lens;
(ii) Intraocular
foreign body;
(iii) Ocular
trauma;
(iv) Phacogenic
glaucoma;
(v) Phacogenic
uveitis;
(vi) Phacoanaphylactic
endopthalmitis; or
(vii) Increased
ocular pressure in a person who is blind and is experiencing ocular
pain.
(7) The
agency covers strabismus surgery as follows:
(a) For clients age seventeen and younger.
The provider must clearly document the need in the client's record. The agency
does not require authorization for clients age seventeen and younger;
and
(b) For clients age eighteen
and older, when the clinical criteria are met. To receive payment, providers
must follow the expedited prior authorization process. The clinical criteria
are:
(i) The client has double vision;
and
(ii) The surgery is not being
performed for cosmetic reasons.
(8) The agency covers blepharoplasty or
blepharoptosis surgery for clients when all of the clinical criteria are met.
To receive payment, providers must follow the agency's expedited prior
authorization process. The clinical criteria are:
(a) The client's excess upper eyelid skin is
blocking the superior visual field; and
(b) The blocked vision is within ten degrees
of central fixation using a central visual field test.
11-14-075, recodified as §182-531-1000, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090. 11-14-055, § 388-531-1000,
filed 6/29/11, effective 7/30/11. Statutory Authority:
RCW
74.08.090,
74.09.520. 01-01-012, §
388-531-1000, filed 12/6/00, effective
1/6/01.
