Article

Contact Lens Practice Pearls

Medically Necessary Contact Lenses—Will Insurance Help?

Contact Lens Practice Pearls

Medically Necessary Contact Lenses—Will Insurance Help?

BY JESSICA H. MATHEW, OD, PHD, FAAO

Each month, most of us grudgingly pay our health insurance premiums, hoping they will pay off and cover our medical expenses when we really need it. This is undoubtedly true for vision insurance as well. As a healthcare provider, there is nothing worse than having to tell patients that the vision insurance plan that they faithfully pay does not cover the type of eyewear necessary to correct their vision.

I’m talking about those patients who require “medically necessary” contact lenses—specialty contact lenses that provide better vision than what spectacles or standard soft contact lenses can provide.

Examples of these lenses include scleral, hybrid, and other GP lenses. Although this group may be small in the grand scheme of things, these patients rely heavily on specialty contact lenses to gain functional everyday vision that many of the rest of us take for granted.

Qualifying Diagnoses

The term “medically necessary” almost implies that insurance plans would recognize this need and guarantee coverage. However, this has not always been the case, and getting coverage has not always been possible or has been tricky at the very least. With recent changes in healthcare plans, more insurance companies are recognizing certain specified diagnoses as qualifying for medically necessary contact lenses (Table 1).

TABLE 1 Medically Necessary Diagnoses Recognized by Vision Insurance Plans (not all inclusive)
DIAGNOSIS ICD-9 CODE
Keratoconus 371.60, 371.61, 371.62
Irregular corneal astigmatism 367.22
Aphakia 379.31
High ametropia (>–10.00D or +10.00D)* 367.9
Anisometropia (>3.50D)* 361.31
Vision improvement* 367.9
Corneal deformity 743.41, 371.70
Facial deformity 738.19, 754.0
*Specific parameters are different per insurance provider

This shift in healthcare gives patients more affordable options, especially since these lenses tend to be more expensive. And, it opens up the playing field for physicians, allowing them to prescribe the best available option without the worry of what patients can or cannot afford.

Reimbursements are also respectable, with some plans allowing up to $2,500 for lenses plus a fitting fee, so you are likely to be fully compensated. Note: A pre-authorization prior to an actual lens fitting is sometimes required.

Training your staff to be familiar with the process of verifying insurances ahead of time for medically necessary contact lens eligibility is essential for exam efficiency. They should also be accustomed to filing these claims, as it is necessary to use approved ICD-9 codes to maximize reimbursements. Following these steps will ensure a win-win for both patient and practitioner. CLS


Dr. Mathew is a research assistant professor at the University of Houston College of Optometry. She manages patients who have severe corneal distortions and require specialty contact lenses, and she is also involved in basic science and clinical trial research with The Ocular Surface Institute. She has received research funding from Allergan, CooperVision, Clearlab, Essilor, Shire, TearLab, Menicon, and Vistakon. You can reach her at jmathew@optometry.uh.edu.