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PDFWAC 182-531-1000

Ophthalmic services.

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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-531-1000, filed 6/29/17, effective 7/30/17. 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.]
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