Eyeglasses - Medical Necessity Criteria

Criteria for documenting medical necessity of eyeglasses

Contents:

Does health insurance cover eyeglasses?
When are eyeglasses medically necessary?
Medical necessity criteria for eyeglasses
Does Medicare cover eyeglasses?
Documentation to submit
Health plan criteria for eyeglasses and other references

Does health insurance cover eyeglasses?

Vision coverage (including eyeglasses) is required in all plans in the Health Insurance Marketplace for children, but is only included in some plans for adults.

Many medical plans exclude coverage of eyeglasses unless the individual has a vision care plan that covers refractive lenses.

However, even medical plans can cover eyeglasses if these are medically necessary for a patient’s condition.

When are eyeglasses medically necessary?

Generally, eyeglasses are considered medically necessary after cataract surgery without intraocular lens placement. Depending on the individual’s health plan, eyeglasses may also be considered medically necessary when a correction of .50 diopters or greater in sphere or cylinder power in either eye is required. Always check the terms and conditions in the individual’s benefit plan contract, since not all plans have vision coverage.

Medical necessity criteria for eyeglasses

One set of eyeglasses may be considered medically necessary for people who have:

Aphakia (no lens) after cataract surgery without intraocular lens placement
Aniridia
Anisometropia (more than 3.0 diopters)
High myopia (more than 14.0 diopters)
Keratoconus
Persistent epithelial defects
Post corneal transplant perforations

For plans that do cover eyeglasses for errors of refraction:

Initial eyeglasses may be considered medically necessary when a correction of .50 diopters or greater in sphere or cylinder power in either eye is required.
Replacement eyeglasses may be considered medically necessary in the following situations:
- A change in correction of 0.5 diopters or greater in either sphere or cylinder power in either eye
- A shift in axis of greater than 10 degrees in either eye
- A change in head size that makes a new pair of eyeglasses necessary
- An allergic reaction to the previous pair of eyeglass frames
- Lost, broken or irreparably damaged eyeglasses, as explained in a statement written by the patient or their caregiver

For those people who meet the medical necessity criteria for refractive lenses, standard eyeglass frames are also considered medically necessary.

The following items or features are generally considered NOT medically necessary unless the treating physician can justify and document their medical necessity:

Anti-reflective coating
Colored, highly-reflective lens treatments
Deluxe frames
Eyeglass cases
Eyeglasses for cosmetic purposes only
Oversize lenses
Polarization
Progressive lenses
Scratch resistant coating
Supplies used to clean or otherwise maintain lenses
Tints

Reminder: Coverage and medical necessity is always dependent on the terms, conditions, and policies of the individual’s plan.

Does Medicare cover eyeglasses?

Usually, Medicare will not cover eyeglasses or contact lenses. However, there are exceptions to this rule.

Medicare covers eyeglasses and other refractive lenses for individuals who lack a natural lens because of either congenital absence or surgical removal. The diagnoses for which eyeglasses will be covered are limited to:

congenital aphakia – a condition in which someone has had no natural lens since birth
pseudophakia – a condition in which the natural lens has been replaced with an artificial intraocular lens
aphakia – a condition in which the natural lens has been removed and has not been replaced by an intraocular lens

Documentation to Submit

These are the things you can prepare documentation of in order to support your statement that eyeglasses are medically necessary. Submit only those that apply.

Documentation of correction of .50 diopters or greater in either sphere or cylinder power in either eye - for initial eyeglasses

Documentation of a medical condition that may be affected or aggravated by bright light or changing light conditions - for specialty lenses

Documentation that patient is undergoing cataract surgery with implantation of an intraocular lens

For specialty lenses:

Documentation that patient has achromatopsia

Documentation that patient has albinism

Documentation that patient has aniridia

Documentation that patient has blue cone monochromatism

Documentation that patient has cystinosis

Documentation that patient has retinitis pigmentosa

Documentation that patient has functional vision in only one eye

For replacement eyeglasses: