At A Glance

  • The goal of medically necessary contact lenses (MNCLs) is to restore functional vision in individuals with an ocular pathology for whom standard spectacle or contact lens correction does not provide an adequate improvement in vision.
  • Any type of contact lens material or modality may be used as an MNCL.
  • Many insurance companies require prior authorization for MNCLs.

Medical necessity is defined by the American Medical Association as “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”1

When it comes to contact lenses, the definition of medical necessity should also be well defined; however, there is much confusion. Any type of contact lens material or modality can be a medically necessary contact lens (MNCL). What distinguishes an MNCL from a contact lens used solely for vision correction is function, not form. That is, the goal of MNCLs is not solely to improve vision but rather to restore functional vision in individuals with an ocular pathology for whom standard spectacle or contact lens correction does not provide adequate improvement in vision.

The ocular pathology can be due to any condition that produces an irregular, distorted, dysfunctional, or scarred ocular surface. There are many circumstances that lead to corneal irregularity and are thus indications for MNCLs (see Indications for MNCLs). Most of these conditions involve irregular corneal astigmatism or ocular surface disease, either of which can vary in presentation from mild to moderate to severe. MNCLs may be used for those with corneal irregularities who require visual rehabilitation, such as keratoconus.

Indications for MNCLs

Conditions that warrant the medical use of contact lenses for treatment of the ocular surface include the following.

- Primary corneal ectasias

  • keratoconus (Figure)
  • keratoglobus
  • pellucid marginal degeneration

- Secondary corneal ectasias

  • postsurgical ectasia (eg, after LASIK, PRK, or RK)

- Corneal transplantation

- Trauma

- Corneal scars

- Corneal degenerations or dystrophies

  • Salzmann nodular degeneration
  • Terrien marginal degeneration

- Severe ocular surface disease

  • graft-versus-host disease
  • Sjögren syndrome
  • Stevens-Johnson syndrome
  • neurotrophic keratopathy
  • exposure keratitis
  • dry eye syndrome
  • ocular cicatricial pemphigoid
  • limbal stem cell deficiency
  • persistent epithelial defect

- High refractive error

- Significant anisometropia

- Facial defects or palsies that preclude the use of glasses

- Diplopia

- Polypopia

- Monocular or binocular diplopia

- Photophobia

Figure. An image of advanced keratoconus requiring a medically necessary contact lens.
Photo courtesy of Melissa Barnett, OD, FAAO, FSLS, FBCLA.

The post-lens fluid layer, between the posterior surface of a scleral lens and the anterior surface of the cornea, acts as a tear reservoir to constantly bathe the cornea. The beauty of a tear reservoir is that it can dramatically improve one’s comfort and the symptoms of dry eye. A scleral lens also functions as a barrier between the ocular surface and the environment, which again helps protect the ocular surface.

Scleral lenses can improve corneal epithelial integrity, vision-related quality of life, and visual acuity in those with ocular surface disease.2,3 A significant improvement in quality of life in clinical practice has been demonstrated for those who were not helped by or were intolerant of conventional gas permeable contact lenses.4

THE GOODS

As noted above, any type of contact lens material or modality can be an MNCL. They are not limited to corneal gas permeable or scleral gas permeable contact lenses (Figure 1). Even a custom soft, hybrid, piggyback, or prosthetic lens can serve as an MNCL (Figure 2). In addition, the type of contact lens may differ from eye to eye. For example, a patient with anisometropia and corneal scarring may wear a soft daily replacement lens on the nonscarred eye and a scleral lens on the eye with scarring. In other cases, only one MNCL may be necessary.

<p>Figure 1. A keratoconic eye fit with a corneal gas permeable contact lens.<br />
Photo courtesy of Tom Arnold, OD, FSLS.</p>

Click to view larger

Figure 1. A keratoconic eye fit with a corneal gas permeable contact lens.
Photo courtesy of Tom Arnold, OD, FSLS.

<p>Figure 2. A disfigured eye fit with a soft prosthetic contact lens.<br />
Photo courtesy of Melissa Barnett, OD, FAAO, FSLS, FBCLA.</p>

Click to view larger

Figure 2. A disfigured eye fit with a soft prosthetic contact lens.
Photo courtesy of Melissa Barnett, OD, FAAO, FSLS, FBCLA.

MNCLs are not the same as contact lenses used solely for vision correction because the former are used to address a specific medical condition. However, the type of contact lens may be the same as one used to solely correct vision. For example, a corneal gas permeable contact lens may be used to correct refractive error, or a customized, special design may be used in a patient with keratoconus.

BUSINESS MATTERS

Establishing Medical Necessity

When practitioners prescribe MNCLs, establishing and documenting true medical necessity is vital. Documentation should include the specific pathology with respect to the contact lens fit. Before fitting MNCLs, the practitioner and practice staff should be prepared with clinical protocols and procedures. Thus, appropriate staff training is a necessity. It is helpful to obtain patients’ previous ocular records and to verify their insurance benefits before scheduling an examination in order to maximize efficiency.

Obtaining Prior Authorization

Obtaining prior authorization from insurance companies for MNCLs can be frustrating, tedious, and time-consuming, but it is often necessary to obtain reimbursement. Coverage for MNCLs may be provided by medical or vision insurance companies. When a patient calls to arrange an appointment, it is important to gather the necessary information in order to verify coverage and determine whether medical or vision insurance will be billed. Relevant information includes the patient’s eligibility for MNCLs under his or her insurance plans and the initial eligibility date.

Be mindful that some insurance plans require prior authorization while others do not.

Fee schedules may differ between vision and medical insurance plans. Vision insurance providers such as VSP and EyeMed typically incorporate the lens fitting and lenses into one lump sum with a specific global time period. The lump sum payment includes the contact lens fitting, contact lenses, dispensing, and subsequent visits within the global period. Medical insurance plans pay for the fitting and the lenses as separate charges. All subsequent visits are then billed as distinct charges.

Information from the eye examination is required for the prior authorization to verify that the patient qualifies for MNCL coverage. Information requested from the insurance company may include the patient’s BCVA with glasses and with specialty contact lenses, the diagnosis associated with the contact lens fitting, and the corresponding diagnosis, procedure, and material codes.

An insurance company may request the provider’s usual and customary fees, plus documentation from the visit. A contact lens contract or waiver between the patient and the practitioner is recommended to document fees, the fitting timeframe (for example 90 days), and potential responsibilities of the patient. Before the initial visit, it is ideal to review insurance eligibility so that both practitioner and patient are cognizant of potential costs involved in the MNCL fitting.

ARE MNCLS FOR YOU?

If you are interested in incorporating prescription of MNCLs into your practice, examine your current patient population. Start by looking at patients with high refractive error or anisometropia. Evaluate their vision insurance plans to see if they cover MNCLs. Review which of your existing patients with dry eye disease might benefit from scleral lenses to protect and lubricate the ocular surface. Then evaluate their coverage to determine whether medical or vision insurance could be used to bill for MNCLs.

When you discuss MNCLs with patients, it is important for the patients to understand why the lenses are being fit. They must also understand that the contact lens fitting is a process and may take several visits. Be sure to set realistic expectations of what you hope to achieve with contact lenses. When practitioners prescribe MNCLs, establishing and documenting true medical necessity is pertinent. Documenting should include the specific pathology in respect to the contact lens fit.

Specialty MNCLs can improve the quality of life for your patients by improving their vision and comfort. In addition, these specialty lenses may be profitable and a good source of revenue for your practice. For additional information on MNCLs, see Resources.

Resources

Gas Permeable Lens Institute
gpli.info

Scleral Lens Society
sclerallens.org

National Keratoconus Foundation
www.nkcf.org

Sjögren’s Syndrome Foundation
www.sjogrens.org

1. Definitions of “Screening” and “Medical Necessity.” American Medical Association. 2016. https://policysearch.ama-assn.org/policyfinder/detail/H-320.953?uri=%2FAMADoc%2FHOD.xml-0-2625.xml. Accessed February 12, 2020.

2. Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015;26(4):319-324.

3. Carrasquillo KG, Lipson MJ, Ezekiel DJ, et al. Scleral lens complications and problem solving. In: Barnett M, Johns LK, eds. Contemporary Scleral Lenses: Theory and Application. Sharjah, UAE: Bentham Science; 2017:373-421.

4. Picot C, Gauthier AS, Campolmi N, Delbosc B. Quality of life in patients wearing scleral lenses. J Fr Ophtalmol. 2015;38(7):615-619.