Scleral lenses are specialized, large-diameter gas-permeable contact lenses designed to vault completely over the cornea and rest on the white part of the eye, the sclera. This unique fit creates a fluid reservoir between the lens and the cornea, providing a smooth optical surface for clear vision and therapeutic hydration. Coverage for these lenses depends entirely on the underlying reason for their use. If the lens corrects a standard refractive error, it is typically excluded, but if it treats a medical condition, coverage becomes a possibility.
The Dual Nature of Coverage: Medical vs. Vision Plans
A fundamental distinction exists between vision plans and medical insurance regarding coverage for specialized devices like scleral lenses. Vision plans, such as VSP or EyeMed, primarily cover routine eye exams, standard eyeglasses, and conventional contact lenses for common refractive errors. These plans generally view scleral lenses as a non-essential, specialized item and often exclude them unless an optional rider for “medically necessary contact lenses” is part of the policy.
The primary route for securing coverage is through your major medical insurance plan, which treats the eyes as part of the overall body. Medical plans operate on the principle of necessity, covering a device or procedure only if required to treat a diagnosed medical disease or injury. For coverage, a scleral lens must be reclassified from a vision correction tool to a non-elective medical device or prosthetic. This reclassification shifts the financial responsibility from the limited allowances of a vision plan to the broader coverage framework of a medical plan.
Vision plans that offer a benefit for medically necessary lenses often provide a fixed, sometimes low, allowance that may not cover the high cost of custom scleral lenses and their complex fitting process. In contrast, medical insurance can cover a much larger percentage of the total cost, provided the strict criteria for “medical necessity” are met. This difference is why many eye care providers first bill medical insurance for the lenses and the associated professional fitting services.
Establishing Medical Necessity for Coverage
The key to unlocking medical insurance coverage is demonstrating that the scleral lens is the only viable treatment option to restore functional vision or ocular health. This requires a specific medical diagnosis confirming the patient cannot achieve adequate vision or comfort with standard eyeglasses or soft contact lenses. The most common conditions accepted by insurers involve severe corneal irregularities, where the eye’s shape is distorted enough that standard correction fails.
A primary example is Keratoconus, a progressive condition where the cornea thins and bulges into a cone shape. Scleral lenses effectively neutralize this by providing a smooth optical surface. Other corneal ectasias, such as Pellucid Marginal Degeneration or post-LASIK ectasia, are also recognized as qualifying conditions. A scleral lens may also be deemed necessary following a penetrating keratoplasty or other corneal surgeries when the resulting surface irregularity cannot be corrected otherwise.
Medical necessity can also be established for therapeutic purposes beyond vision correction, particularly for severe ocular surface diseases. Chronic conditions like Sjögren’s syndrome, severe dry eye syndrome, or ocular complications from Stevens-Johnson syndrome often cause extreme dryness and damage. In these cases, the scleral lens acts as a protective prosthetic device, creating a fluid-filled vault that continuously bathes and protects the cornea. Insurers often view this therapeutic benefit as a medical treatment rather than a refractive correction.
Practical Steps for Securing Insurance Approval
The administrative process for securing approval for scleral lenses is complex and requires meticulous preparation by the eye care provider. The first step usually involves the provider submitting a request for Prior Authorization (PA) to the medical insurer. This formal request seeks approval before services are rendered, confirming the treatment meets the plan’s criteria for coverage.
The success of the PA relies heavily on thorough documentation justifying the medical necessity of the lens. This documentation must include specific diagnostic data, such as corneal topography maps, to illustrate the severity of the irregularity and the history of failed attempts with conventional treatments. The provider must use appropriate medical billing codes—ICD codes for the diagnosis and CPT codes for the fitting services and the lenses—to communicate the medical nature of the service.
If the initial PA request is denied, the next step is a formal appeal. The provider plays a central role by drafting a detailed Letter of Medical Necessity (LMN), which serves as a clinical argument for the treatment. This letter often compares the patient’s best-corrected visual acuity with eyeglasses versus the anticipated improvement with the scleral lens, emphasizing functional and quality-of-life benefits. Patients may also be advised to contact the insurer directly to advocate for their case or determine the specific language in their policy regarding prosthetic devices.