Schedule 5 - Appendix A - Surgically Implanted Prostheses

OPHTHALMIC
Billing Code Product Further Size Notations
AP006 Mira: Scleral Implants Solid Bands-Mira 40 Circling Band 2mm,
Silicone-Band/Strip/Boat/Clip. Mira 240 Circling Band 2.5mm.
Retinal Implant used in Scleral Strips-Mira 41 Strip 3.5mm, Mira
Buckling (Dimethylmethylvinyl 42 Strip 4mm, Mira 20 Strip 4mm,
Mira 219 Strip 4.5mm, Mira 31
Strip 4.5mm, Mira 32 Strip 5mm,
Mira 225 Oval Strip 5mm, Mira 220
Strip 6mm. Boats-Mira 60 Boat
2mm, Mira 260 Boat 2.5mm.
Clips-Mira 50 Double Tantalum
Clip 2mm, Mira 250 Double
Tantalum Clip 2.5mm, Mira 51
Singla Tantalum Clip 3.5mm, Mira
52 Joondeph Single Tantalum Clip
4mm
Bausch & Lomb Surgical
Lenses, Intraocular, Anterior Chamber
BL005 Storz (Coburn) Intraocular Lens PMMA Anterior Chamber 13.75mm length. 6.0mm optic size,
Intraocular lens 1 piece diopter range 3-30d
Lenses, Intraocular, Posterior Chamber
BL006 Posterior chamber IOLS model P359 PMMA Posterior Chamber lens 1 12.25mm to 13.75mm length. 5.5mm
UV, P399 UV, 68 UV, 95 BUV, or to 7mm optic size, diopter range
lolab PC One Piece, model 6741B, -4.5 - 45d to 10 - 34d
8591B, 8191B
BL007 Hydroview Intraocular lens Model Foldable Hydrogel Lens Hydrogel 12.50mm length, 6.0mm optic size,
Posterior Chamber Foldable lens 1 diopter range 15-30d
piece
BL009 Soflex UV Absorbing Silicone Foldable Intraocular Lens Silicone 13.00mm length, 6.0mm optic size,
Posterior Chamber IOL Model LI61U Posterior Chamber Foldable Lens 3 diopter range 5-30d
piece
BL010 Chiroflex Model C11UB Intraocular Lens Foldable Plate 10.50m length, 6.0mm optic size,
Haptic Silicone Posterior Chamber diopter range 10-30d
Foldable Plate Haptic Lens 1 piece
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