An estimated 45 million Americans wear contact lenses with the most common reason being for nearsightedness. Contact lenses are worn to replace glasses wear but are more than a means for cosmetic correction—they are recognized as a medical device by the FDA. When it comes to irregular corneas or high refractive error, glasses and corrective surgery are not always an option, and medically necessary contact lenses come into play.
Medically necessary contact lenses are not elective and are often the only treatment option that provides optimal vision for patients with ocular conditions such as Keratoconus or systemic conditions that cause severe dry eye like Sjogren’s Syndrome. Contact lenses can improve visual acuity and reduce visual distortion in ways glasses cannot and ultimately improve your patient’s quality of life.
What are medically necessary contact lenses?
Currently, there is not a universal definition of what constitutes medically necessary contact lenses as many lens types can be considered medically necessary. Medically necessary contact lenses can range from soft contact lenses (including disposable lenses or extended wear lenses) to hard lenses (including rigid gas permeables or scleral lenses). Hybrid contact lenses, which consist of rigid gas permeables with a soft lens skirt, can also be a treatment of choice for vision correction. Medically necessary contact lenses do not always require a specialty fit and can be as simple as spherical soft contact lenses.
Each vision and health plan defines medically necessary contact lenses with a different set of parameters and medical diagnoses. By using your clinical judgment and the proper diagnosis, you can select patients who will benefit from medically necessary contact lenses and improve the quality of care you’re able to provide them. This guide is designed to help you maneuver through vision insurance plans, learn which plans provide what coverage, and get a basic understanding of the procedural codes used for billing.
Vision Insurance Plans
A unique aspect of EyeMed is that vision improvement with contact lenses, even without a medical diagnosis, can be considered medically necessary without a refractive error requirement.
- Anisometropia exceeding 3D in meridian powers
- High Ametropia exceeding -10D or +10D spherical equivalent in one or both eyes
- Keratoconus where the patient is not correctable to 20/30 in either or both eyes in standard spectacle correction
- Vision Improvement for patients whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses
On the other hand, Davis Vision requires that contact lenses must improve visual acuity by 2 lines AND meet a refractive error requirement.
- Anisometropia exceeding 3D in meridian powers
- High Ametropia exceeding -7.00D or +7.00D spherical equivalent in one or both eyes based on the spectacle prescription
- AND spectacle best corrected visual acuity of 20/40 of worse in either eye
- AND visual acuity improvement of 2 lines or more with contact lenses
- Keratoconus (Ectatic Corneal Dystrophy)
- Aphakia for Medicare members only
- Irregular Astigmatism of 2 diopters of astigmatism in either eye, with principal meridian separated by less than 90 degrees.
Compared to other vision insurance plans, Superior Vision does not constitute high Ametropia alone as a requirement for medically necessary contact lenses.
- Anisometropia of 4.0D or more, provided visual acuity improves to 20/60 or better in the weaker eye.
- Aphakia (after cataract surgery) A pair of single vision lenses or multifocal lenses and frames can be provided with the contact lenses.
- Vision Improvement when visual acuity cannot be corrected to 20/70 in the better eye except through the use of contact lenses (must be 20/60 or better)
Irregular Astigmatism billed as the primary medical diagnosis does not qualify as medically necessary under VSP. Irregular Astigmatism is considered a condition caused by an underlying disorder such as Keratoconus.
- Anisometropia exceeding 3D meridian power based on the spectacle prescription
- High Ametropia exceeding ±10.00 in one or both eyes based on the spectacle prescription
- Hereditary Corneal Dystrophies
Colored contact lenses for the following conditions are also a covered benefit:
- Congenital Anisocoria
- Pupil abnormalities
Contacts with spectacle lenses to wear over contacts for the following conditions are a covered benefit as well:
- High Ametropia
- Accommodative Disorder
- Binocular Function Disorder
- Different prism requirements for distance and near
Medicare helps pay for either one pair of eyeglasses with standard frames or one set of contact lenses. This only applies to Medicare Part B for one-time use for the following:
Working with a variety of vision insurance plans will require proper credentialing for each. Check out our Ultimate Guide to Optometry Credentialing!
General Billing and Coding
Once you’ve determined the patient qualifies for medically necessary contact lenses, you must select the proper code for the contact lens they are being fitted for.
Current Procedural Terminology (CPT)
|92310||Corneal Lens, Both Eyes, Except for Aphakia|
|92311||Corneal Lens for Aphakia, One Eye|
|92312||Corneal Lens for Aphakia, Both Eyes|
|92071||Contact Lens for Treatment of Ocular Surface Disease|
|92072||Contact Lens for Management of Keratoconus|
NOTE: CPT code 92071 and 92072 are not meant to be used simultaneously, it’s one or the other
Healthcare Common Procedure Coding System (HCPCS)
|V2510||Contact Lens, GP, Spherical|
|V2511||Contact Lens, GP, Toric|
|V2512||Contact Lens, GP, Bifocal|
|V2513||Contact Lens, GP, Extended Wear|
|V2520||Contact Lens, Hydrophilic, Spherical|
|V2521||Contact Lens, Hydrophilic, Toric|
|V2522||Contact Lens, Hydrophilic, Bifocal|
|V2523||Contact Lens, Hydrophilic, Extended Wear|
|V2531||Contact Lens, GP, Scleral|
|V2627||Scleral Cover Shell|
|V2599||Contact Lens, Other Type (Hybrid, Hand Painted Prosthetics)|
With the proper testing, diagnosis, and billing codes, your role as an eyecare provider can transform the lives of your patients. For patients with underlying ocular conditions that impact vision, contact lenses are much more than a cosmetic choice—they are a necessary treatment option that meets their visual needs and provides the comfort and confidence to complete day to day tasks and enjoy leisure activities.
It is vital as an eyecare provider that you diligently screen patients and fit contact lenses as medical devices. Educate your patients on why a medical device is covered through their vision plan and provide the options that are available to them. Though it is important to note that a “medical diagnosis” is not always required—it can be as simple as anisometropia to qualify for contact lens correction in a medical capacity. With word of mouth being the biggest source of referral, this will not only promote your practice, but it will also raise awareness to the masses that optometry has a role in medical care and can provide treatments that can have a lasting impact.