Reminder: Criteria for Polycarbonate Eyeglass Lenses

Providers may request prior approval for polycarbonate lenses without medical justification or additional documentation when eligible beneficiaries meet at least one of the following criteria:

• Age is birth through 6 years old;
• Single vision or bifocal correction with + or – 5.00 diopters or more in one meridian (sphere, cylinder, combination of sphere and cylinder or prism) in one eye;
• Beneficiary is blind or legally blind in one eye, with correction for the sighted eye in accordance with clinical coverage policy 6A, subsection 5.6.1; Note "Blind" or "Legally blind" and best corrected visual acuity in the Note field.

For any condition not listed above, the provider must submit documentation of medical necessity for polycarbonate lenses with the prior approval request. Each prior approval request will be reviewed for medical necessity on an individual basis.

To access the full policy refer to 6A Routine Eye Exams and Visual Services for Beneficiaries Under Age 21.