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WAC 182-531-1000

Agency filings affecting this section

Ophthalmic services.

Refer to chapter 388-544 WAC for vision-related hardware coverage for clients twenty years of age and younger.
(1) The department covers, without prior authorization, eye examinations, refraction and fitting services with the following limitations:
(a) Once every twenty-four months for asymptomatic clients twenty-one years of age and older;
(b) Once every twelve months for asymptomatic clients twenty years of age and younger; or
(c) Once every twelve months, regardless of age, for asymptomatic clients of the division of developmental disabilities.
(2) The department covers additional examinations and refraction services outside the limitations described in subsection (1) of this section 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) The service is necessary due to lost or broken eyeglasses/contacts. In this case:
(i) No type of authorization is required for clients twenty years of age or younger or for clients of the division of developmental disabilities, regardless of age.
(ii) Providers must follow the department's expedited prior authorization process to receive payment for clients twenty-one years of age 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 department 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 department covers orthoptics and vision training therapy. Providers must obtain prior authorization from the department.
(5) The department 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 department 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 department covers strabismus surgery as follows:
(a) For clients seventeen years of age and younger. The provider must clearly document the need in the client's record. The department does not require authorization for clients seventeen years of age and younger; and
(b) For clients eighteen years of age 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 department covers blepharoplasty or blepharoptosis surgery for clients when all of the clinical criteria are met. To receive payment, providers must follow the department'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.
[WSR 11-14-075, recodified as § 182-531-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1000, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1000, filed 12/6/00, effective 1/6/01.]