Contact Lenses - Medical Necessity Criteria
Criteria for documenting medical necessity of contact lenses
Contents:
- Does insurance cover medically necessary contact lenses?
- When are contact lenses considered medically necessary?
- Medical necessity criteria for contact lenses
- Medical necessity criteria for therapeutic hydrophilic contact lenses
- Medical necessity criteria for scleral shell contact lenses
- Health plan criteria for contact lenses and other references
Does insurance cover medically necessary contact lenses?
Coverage of contact lenses depends on the kind of insurance plan a person has.
Many medical plans exclude coverage of contact lenses and eyeglasses. However, some individuals may have supplemental coverage for frames and lenses.
Even medical plans that normally don’t cover contact lenses may provide coverage if the patient has a medical condition (such as aphakia) for which contact lenses have been determined to be a medically necessary part of treatment.
When are contact lenses considered medically necessary?
Conditions for which contact lenses may be considered medically necessary include, but are not limited to, aphakia, keratoconus, and severe ocular surface diseases. It’s best to consult the medical necessity criteria used by the patient’s health plan.
Medical necessity criteria for contact lenses
If contact lenses are covered under the patient’s plan, these are some of the indications for which they may be considered medically necessary:
- Correction of refractive error *
- After cataract surgery – when no intraocular lens has been implanted
- Anisometropia or antimetropia – when the difference is two diopters ** or greater and results in aniseikonia
- Aphakia – congenital or surgical
- Astigmatism – when 3 diopters or moreCongenital cataracts
- Hyperopia – when more than 7 diopters
- Keratoconus – if vision cannot be corrected to 20/40 or better with eyeglasses
- Myopia – when more than 7 diopters ***
- Persistent epithelial defects
- Post corneal transplant perforations
Limitations/exclusions:
- Contact lenses that will be used for routine vision correction or cosmetic purposes are NOT considered medically necessary.
- Cleaning solutions and other supplies used to clean or maintain contact lenses are generally not covered.
- “Add-ons” such as tints and progressive lenses are not covered.
Notes:
* Even under medical plans, an initial pair of contact lenses may be considered medically necessary when they are prescribed by a physician to correct a change in vision that resulted directly from an accidental bodily injury. However, replacements would generally not be covered.
** Some health plans require 3 diopters or more.
*** Some health plans require more than 12 or more than 14 diopters.
Medical necessity criteria for therapeutic hydrophilic contact lenses
If therapeutic soft (hydrophilic) contact lenses or gas-permeable fluid ventilated scleral lenses (such as the Boston Scleral Lens and PVR PROSE Scleral Lens) are covered under the patient’s plan, they may be considered medically necessary when used as moist corneal bandages for the treatment of acute or chronic corneal pathology, including:
- acute corneal abrasion
- aniridia
- anterior corneal dystrophy
- autoimmune disease-related corneal disorders
- bullous keratopathy
- corneal ectasia
- corneal edema
- corneal exposure (e.g., anatomic, paralytic)
- corneal stem cell deficiency
- corneal ulcers and erosion
- descemetocele
- dry eyes (keratoconjunctivitis sicca)
- epidermal ocular disorders (e.g., atopy, ectodermal dysplasia, epidermolysis bullosa)
- keratitis
- Mooren’s ulcer
- neurotrophic/anesthetic corneas
- neurotrophic keratoconjunctivitis
- poorly healing eye wounds
Even with plans that exclude coverage of contact lenses, liquid bandage scleral lenses may still be covered when medically necessary, as they are not primarily used for correction of refractive errors.
Hydrophilic contact lenses are not covered when used in the treatment of non-diseased eyes with corneal astigmatism, refractive astigmatism, and/or spherical ametropia.
Medical necessity criteria for scleral shell contact lenses
Scleral shell contact lenses may be considered medically necessary for:
- Patients whose eyes have shrunken and been rendered sightless by inflammatory disease — in this case, the lens serves essentially as an artificial eye
- Keratoconjunctivitis sicca or “dry eye” of diverse etiology when used in combination with artificial tears — in this case, the lens acts as a substitute for the diseased lacrimal gland and would be covered as a prosthetic device
Even with plans that exclude coverage of contact lenses, scleral shell lenses may still be covered when medically necessary, as they are not primarily used for correction of refractive errors.
Health plan criteria for contact lenses and other references
- Aetna Criteria for Contact Lenses and Eyeglasses
- Health Net Vision PPO Frequently Asked Questions
- Tufts Health Plan Medical Necessity Guidelines for Therapeutic Lenses
- UnitedHealthcare West Policy on Vision Care and Services