V2623 HCPCS Code — Prosthetic Eye Insurance & Reimbursement Guide 2026
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Quick answer: HCPCS code V2623 is the insurance billing code for a plastic (acrylic) prosthetic eye. Medicare Part B covers it (typically ~$2,900-3,500 depending on your MAC region), most private insurers follow Medicare's lead, and Medicaid coverage varies by state. Documentation from your ocularist and a letter of medical necessity are required in almost all cases.
What is HCPCS code V2623?
V2623 is the Healthcare Common Procedure Coding System (HCPCS) code used to bill insurers for a plastic eye prosthesis, custom. It falls under the DME (Durable Medical Equipment) benefit category and is administered through your DME MAC (Medicare Administrative Contractor). If you're purchasing an ocular prosthetic eye, this is the code your ocularist or optical shop will use to submit for reimbursement.
Related codes you may see on the same claim:
- V2624 — Polishing/resurfacing existing prosthesis
- V2625 — Enlargement of ocular prosthesis
- V2626 — Reduction of ocular prosthesis
- V2627 — Scleral cover shell
- V2628 — Fabrication and fitting of ocular conformer (see Ocular Conformer)
- V2629 — Prosthetic eye, other type
2026 reimbursement rates by insurer
Reimbursement varies by geographic region (MAC jurisdiction) and insurer. These are 2026 typical ranges — check with your specific plan for exact rates.
| Insurer | Coverage | Typical reimbursement | Patient responsibility |
|---|---|---|---|
| Medicare Part B | YES — under DME benefit | $2,900 – $3,500 | 20% coinsurance + Part B deductible ($240 in 2026) |
| Medicare Advantage | YES (must follow Medicare rules) | Varies by plan | Plan-specific copay |
| Medicaid | Varies by state | $1,800 – $3,200 | State-dependent |
| Blue Cross / Anthem | Usually yes | $2,500 – $3,800 | Deductible + coinsurance |
| UnitedHealthcare | Usually yes | $2,700 – $3,600 | Plan-specific |
| Aetna | Usually yes | $2,600 – $3,500 | Plan-specific |
| Cigna | Usually yes (prior auth may be required) | $2,500 – $3,500 | Plan-specific |
| Tricare | YES — under Program for Persons with Disabilities | Typically 100% for eligible beneficiaries | Program rules |
| VA Healthcare | YES for eligible veterans | Full coverage through VA facility or authorized ocularist | None for service-connected |
Required documentation for a V2623 claim
Insurers typically require ALL of the following. Missing any one is the #1 reason claims get denied.
- Prescription or referral from an ophthalmologist for the prosthesis
- Letter of Medical Necessity (LMN) — must state the diagnosis (e.g., anophthalmia, phthisis bulbi, enucleation status), medical need, and that a stock/off-the-shelf prosthesis was inadequate
- ICD-10 diagnosis code — common ones: Z90.01 (acquired absence of eye), H44.51 (absolute glaucoma requiring enucleation), Q11.2 (congenital anophthalmia)
- Detailed itemized invoice from the ocularist including V2623 code and manufacturer information
- Proof of custom fabrication — impression records, session notes from the ocularist
How to submit a V2623 claim (5 steps)
- Get the prescription. Your ophthalmologist writes the referral for prosthetic fitting.
- Choose your provider. Ocularist, optometrist, or DME supplier that stocks the prosthesis (SciMed ships direct to ocularists — patients typically don't self-submit for V2623).
- Obtain LMN. Your ophthalmologist writes it. Sample template usually available from the ocularist.
- Pre-authorization. Some insurers (especially Cigna, Aetna PPO variants) require pre-auth. Call your plan first.
- Submit CMS-1500 form. The ocularist or DME supplier files the claim with V2623 code, ICD-10 diagnosis, LMN, and itemized invoice attached.
What if my claim is denied?
Common denial reasons and how to fix them:
| Denial reason | Fix |
|---|---|
| "Not medically necessary" | Have ophthalmologist rewrite LMN with stronger clinical justification. Cite ICD-10 diagnosis clearly. |
| "Bundled with different code" | Verify V2623 is being billed alone (not with V2629). File corrected claim. |
| "No pre-authorization" | Request retroactive pre-auth with clinical documentation. Success rate ~60%. |
| "Provider not in network" | Check DME provider network. If ocularist is out-of-network, may need to switch OR file for out-of-network reimbursement. |
| "Frequency limit exceeded" | Medicare allows 1 new prosthesis every 5 years. If yours is older or damaged, submit photos and repair estimate. |
Frequently asked questions
Can I bill V2623 myself as a patient?
Generally no. V2623 is submitted by DME suppliers, ocularists, or medical providers. If you pay out-of-pocket and want reimbursement, submit CMS-1500 through your insurer's patient claim portal with all supporting documentation.
How often will Medicare pay for a new prosthetic eye?
Medicare's frequency limit is typically 1 prosthesis every 5 years. Exceptions: prosthesis becomes damaged beyond repair, medical/anatomical change requires a different prosthesis, or a pediatric patient's growth requires refitting.
Does V2623 cover pediatric prosthetic eyes?
Yes. Pediatric prostheses may need more frequent replacement due to growth; this is generally covered with proper documentation from the treating pediatric ophthalmologist.
Is there a code for the initial conformer used post-surgery?
Yes — that's HCPCS V2628 for a fabricated ocular conformer used during healing before the custom prosthesis is fit. See our Ocular Conformer page for reimbursement details.
What if I need a scleral cover shell instead?
That's V2627. Used when the eye is intact but disfigured, allowing a thin cover shell to be worn over the natural globe. Different code, different indication than V2623.
Can HSA or FSA funds be used?
Yes. Prosthetic eyes qualify as an IRS Section 213(d) medical expense. If your insurance denies or you have coinsurance, HSA/FSA funds can pay the balance pre-tax.
Related reading:
Disclaimer: This information is for general educational purposes only and does not constitute medical, legal, or billing advice. Insurance coverage varies by plan and jurisdiction. Verify current codes and rates directly with CMS, your specific insurer, and your ocularist. Updated August 2026.