Contact lenses are an excellent alternative to eyeglasses for vision correction. However, not all contact lenses are considered medically necessary and may not be covered by medical insurance plans. In this blog post, we will explore what medically necessary contact lenses are and the conditions that may require their use.

What Are Medically Necessary Contact Lenses?

Contact lenses are considered medical devices by the FDA because they require a prescription from an eye doctor to ensure proper fitting and safe usage. However, most health insurance plans consider glasses as sufficient and may not cover contact lenses as they are considered elective.

But, in some cases, contact lenses are considered medically necessary. These are typically for conditions where standard glasses are unable to provide adequate vision correction.

Below are a few conditions that may require medically necessary contact lenses.

Conditions That May Require Medically Necessary Contact Lenses

There are many conditions that are considered as requiring medically necessary contact lenses. These include corneal ectasias (e.g., keratoconus, keratoglobus or pellucid marginal degeneration) and post-surgical ectasia (e.g., post-LASIK, post-PRK or post-corneal transplant). Aphakia, aniridia, severe dry eye caused by Sjögren’s syndrome, graft-versus-host disease or Stevens-Johnson Syndrome are other examples. They also improve peripheral vision and reduce eye fatigue and glare.

Vision Correction:

• LASIK and PRK Complications
• Radial Keratometry Complications
• High Myopia (Nearsighted)
• High Hyperopia (Farsighted)
• High Astigmatism
• Anisometropia
• Aphakia

Corneal Conditions:

• Pellucid Marginal Degeneration
• Corneal Transplant
• Corneal Trauma or Scarring
• Keratoconus
• Keratoglobus
• Pellucid marginal degeneration

Iris and Eye Movement Conditions:

• Aniridia
• Iris Trauma or Coloboma
• Nystagmus

Dry Eye Conditions:

• Dry Eye
• Sjogren’s Syndrome

High prescription

High prescriptions can be caused by myopia (nearsightedness), hyperopia (farsightedness), or astigmatism. Specialty contact lenses, such as toric lenses for astigmatism, can correct high prescriptions better than standard glasses.

Keratoconus

Keratoconus is a condition in which the cornea, the clear outer layer of the eye, thins and bulges out into a cone shape. This can cause irregular astigmatism, which can result in distorted and blurry vision that can't be corrected with glasses. Specialty hard contact lenses, such as rigid gas permeable lenses and scleral contact lenses, can be used to create a new surface for light to pass through, thereby improving a patient's vision.

Corneal irregularities

In addition to keratoconus, there are other corneal irregularities that may require medically necessary contact lenses, such as pellucid marginal degeneration, post-refractive surgery complications, and corneal ectasia.

Specialty hard contact lenses, such as rigid gas permeable lenses and scleral contact lenses, can be used to create a new surface for light to pass through, thereby improving your vision. Hybrid lenses, which combine the benefits of hard and soft lenses, can also be used to improve your vision.

Aniseikonia

Aniseikonia is a condition in which the eyes have a significant difference in size or shape, resulting in an imbalance in the way that each eye processes visual information. This can cause double vision, headaches, and other visual symptoms. Specialty contact lenses, such as custom-made lenses, can be used to correct for aniseikonia and improve a patient's vision.

Post-surgical vision correction

After cataract surgery, the implanted intraocular lens may not provide optimal vision correction, and contact lenses may be needed to correct any remaining refractive errors. In some cases, contact lenses may also be used to manage complications after corneal transplant surgery.

Severe Dry Eye 

Special contact lenses such as Scleral lenses have a reservoir of liquid that provides day long comfort for someone with severe dry eye disease. The Dry Eye Workshop Study 2 (DEWS2) listed Scleral lenses as an advanced treatment option for severe dry eye. Other conditions may include Sjorgens, and post surgical dry eye. 

Determining eligibility for medically necessary contact lenses

To determine eligibility for medically necessary contact lenses, a comprehensive eye exam is necessary. This includes measurements of visual acuity, refractive error, and corneal shape, as well as an evaluation of the health of the eye. In addition to determining eligibility for medically necessary contact lenses, your eye doctor can also recommend the best type of contact lens for each individual patient. 

If you are unsure what part of your fees are covered by insurance it is best to speak with your eye doctor and schedule an eye exam where your eye doctor can better discuss the specifics of your situation.