Specialized contact lenses are prescribed for specific medical conditions, not routine vision correction. These devices are considered medically necessary when standard eyeglasses or typical soft contact lenses cannot provide adequate functional vision or maintain the health of the eye. Securing these specialized lenses involves a distinct process of diagnosis, fitting, and insurance verification, which differs substantially from obtaining standard corrective lenses.
Defining Medically Necessary Contact Lenses
Medically necessary contact lenses treat underlying eye diseases or conditions that compromise vision or ocular surface health. Necessity is established when standard corrective measures, such as glasses or conventional soft contacts, fail to achieve functional visual acuity or manage a specific medical condition. For most insurance plans, the lenses must offer a clear improvement in vision that glasses cannot provide, often defined by a measurable improvement on the visual acuity chart.
A substantial number of patients requiring these lenses have corneal irregularities, accounting for about 75% of medically necessary fittings. Common conditions include keratoconus, a progressive thinning that causes the cornea to become cone-shaped, and pellucid marginal degeneration, which causes thinning near the lower edge of the cornea. These irregular shapes scatter light and distort vision beyond the correction capability of glasses.
Other qualifying conditions relate to post-surgical complications, such as high astigmatism following a corneal transplant or refractive surgery like LASIK. Certain severe dry eye conditions, including those caused by autoimmune disorders like Sjögren’s Syndrome, also require specialized lenses. In these cases, the lenses act like a protective shield, covering the cornea to provide hydration and aid in ocular surface healing.
The criteria also extend to extreme refractive errors, such as high ametropia exceeding -10 or +10 diopters, or significant differences in prescription between the two eyes (anisometropia). In these scenarios, glasses may cause intolerable side effects like image magnification or minification. The underlying medical condition and the failure of standard correction qualify the lens, not the specific type of lens prescribed (soft, rigid, or hybrid).
The Diagnostic and Fitting Process
Obtaining medically necessary contact lenses typically begins with a referral from a general optometrist to a specialty contact lens fitter or a corneal specialist. These practitioners have the advanced knowledge and equipment required to diagnose and manage complex corneal and ocular surface diseases. They handle a nuanced fitting process that goes beyond a routine contact lens exam.
The initial diagnostic phase involves advanced testing, most notably corneal topography, which maps the precise curvature and elevation of the cornea. This detailed mapping is crucial because it reveals the irregularities that make a standard fit impossible and guides the design of the specialty lens.
The fitting process is more complex, time-consuming, and iterative than for standard soft lenses, often requiring multiple office visits. Specialty lenses are highly customized, unlike standard lenses which come in a limited range of base curves. The practitioner selects from various hardware, such as Rigid Gas Permeable (RGP), Scleral, or Hybrid lenses, based on the patient’s specific corneal shape and condition.
Scleral lenses are large-diameter lenses that vault entirely over the irregular cornea and rest on the white part of the eye (sclera). They create a fluid-filled reservoir to correct vision and hydrate the ocular surface. The fitting involves selecting the appropriate lens diameter, curvature, and landing zone to ensure a comfortable fit that does not impinge on the conjunctiva. Specialized instruments like scleral profilometers are often required to optimize the design and reduce fitting time.
Navigating Medical Insurance Coverage
Coverage for medically necessary contact lenses is typically sought through medical insurance, not routine vision insurance. Medical insurance covers treatment for a diagnosed disease or injury, which is the premise for these specialized lenses. Since many medical carriers may still not cover the lenses, or coverage may be limited, benefit verification is a necessary first step.
The process begins with the prescribing doctor generating a Letter of Medical Necessity (LMN). This document confirms the patient’s specific medical diagnosis and explains why standard correction, such as glasses, fails to restore functional vision or treat the underlying condition. The LMN must be accompanied by clinical documentation, including test results like corneal topography, to validate the claim.
Following the LMN, the next step is obtaining Prior Authorization (PA) from the insurance company before the lenses are ordered. PA is the insurer’s requirement for pre-approval of a service or device, ensuring it meets their medical necessity guidelines before payment. The doctor’s office submits the LMN, clinical notes, and specific billing codes for the insurance company to review and determine coverage.
Filing an Appeal
If the initial claim or prior authorization is denied, the patient has the right to file an internal appeal. This is not uncommon due to the specialized nature of the device. The appeal process involves several steps:
- Contacting the insurer to understand the exact reason for the denial (e.g., insufficient documentation or a non-covered benefit).
- Working with the doctor’s office to gather additional, more compelling documentation.
- Submitting a letter from the specialist detailing the impact on the patient’s quality of life.
- Participating in a “Peer-to-Peer” review, if requested, where the prescribing doctor advocates directly with the insurance company’s medical reviewer.
If the appeal is successful, coverage is typically granted for the lenses and fitting services, often allowing for replacement lenses and a new fitting exam once per year, depending on the specific policy.