V2201 Lens sphere bifocal 4.12-7.0Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens
Status X: statutory exclusion, not paid under the PFS.
1 of 1 payer prior-auth lists that name V2201 require prior authorization or set conditions: UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth under conditions | Age 40+ | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
V2201 appears in 4 coverage policies from Aetna, Capital Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Contact Lenses and Eyeglasses (0126) | covered if criteria are met (range V2100-V2499) | Mar 26, 2026 | payer document |
| Aetna | Corneal Remodeling (0023) | listed, no stance (range V2100-V2499) | Oct 9, 2026 | payer document |
| Aetna | Orthoptic Vision Therapy (0489) | listed, no stance (range V2100-V2499) | Jul 28, 2025 | payer document |
| Capital Blue Cross | Intraocular Lenses, Spectacle Correction, and Iris Prosthesis (MP 6.058) Procedure codes | covered if criteria are met | Mar 1, 2026 | payer document |
Prior authorization required or conditional in LA, OH.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.