Contact Lens (Therapeutic) Form

1

Contact Lens (Therapeutic)- Medical Policy
Updated Revision Effective: February 1, 2025 Policy Number:

UM303POL

Approval Date: 12/19/2024

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Contact Lenses are for correction of vision disturbance or for the treatment of disease or replacement of the lens of the eye. Contact lenses are generally NOT COVERED for vision correction, but are covered when used as Therapeutic Lenses, which provide visual rehabilitation for diseased or altered eyes.

 Line of Business

Commercial:

 Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:

 Refer to criteria under the Policy section in this medical policy, for the following services:

o Therapeutic Hydrophilic Contact Lenses o Scleral Shell/Scleral Contact Lenses (Cover Shell) o Gas permeable scleral lenses o Hard, soft or gas-permeable lenses

 For additional information on Contact Lenses service limitations refer to:

o Commonwealth of Massachusetts, MassHealth, 130 CMR 402.433. https://www.mass.gov/lists/vision-care-manual-for-masshealth-providers

Medicare:
Health New England follows National Coverage Determination (NCD) 80.4, Hydrophilic Contact Lenses for non-diseased eyes and aphakia.
 Health New England follows National Coverage Determination (NCD) 80.5, Scleral Shell for Scleral Shell

2

 Health New England follows National Coverage Determination (NCD) 80.1, Hydrophilic Contact Lens for Corneal Bandage

Policy

I. Therapeutic Contact Lenses (Corneal Bandage)

A. Therapeutic soft (hydrophilic) contact lenses or gas-permeable fluid-ventilated scleral lenses (e.g., Boston Scleral Lens and PVR PROSE Scleral Lens) may be considered MEDICALLY NECESSARY when used as moist corneal bandages for the treatment of acute corneal abrasion, corneal ulcers and erosion, poorly healing eye wounds, or for other therapeutic reasons including but not limited to:

A. Corneal ectatic disorders:

a. Ectasia, post-surgery (irregularities in the cornea leading to disturbances of vision as a result of astigmatism) b. Fuchs’ superficial marginal keratitis (cells in the cornea’s inner layer gradually deteriorate with unknown cause) c. Keratoconus (progressive thinning of the cornea) d. Keratoglobus (rare, degenerative non-inflammatory disorder of eye causing corneal thinning) e. Pellucid marginal degeneration (clear bilateral thinning (ectasia) in the inferior and peripheral region of the cornea) f. Terrien’s marginal degeneration (painless, slowly progressive thinning of the peripheral corneal stroma); OR

B. Corneal scarring and/or vascularization; OR

C. Irregular corneal astigmatism (a refractive error, it is not an eye disease, that causes blurred vision. Blurred vision is due to an irregularly shaped cornea or because of curvature of lens inside the eye.) after keratoplasty or other corneal surgery; OR

D. Ocular surface disease with pain and/or decreased visual acuity:

a. Dry eye, severe b. Epithelial defects, persistent c. Exposure keratopathy (eyelid does not protect the cornea enough) d. Graft vs. host disease e. Mucous membrane pemphigoid (blisters that form on the mucous
membranes) f. Neurotrophic keratopathy (degenerative corneal disease induced by trigeminal nerve impairment) g. Post-ocular surface tumor excision h. Post-glaucoma filtering surgery; OR

3

E. Stevens Johnson syndrome sequelae (varies between mild mucopurulent conjunctivitis and severe perforating corneal ulcers)

B. Scleral Shell/Scleral Contact Lenses (Cover Shell): Lenses may be MEDICALLY NECESSARY, when all of the following are met:

A. Member has keratoconus; AND

B. Member is unable to be fitted for a conventional contact lens; AND

C. Treatment of an eye rendered sightless and shrunken by inflammatory disease; AND

D. Treatment of “dry eye” where the device serves as a substitute for the function of the diseased lacrimal gland such as keratoconjunctivitis sicca

C. Gas permeable scleral lenses may be MEDICALLY NECESSARY when used for:

1. Post-cataract surgery with insertion on intraocular lenses; OR

2. Treatment of aphakia (absence of the natural lens)

   D. Scleral Contact Lenses (Cover shell) may be considered MEDICALLY NECESSARY for the following;

3. Treats eyes rendered sightless and shrunken by inflammatory disease. Scleral shell may avoid surgical enucleation (removal of eye) and prosthetic implant and also act to support the surrounding orbital tissue;
   OR

4. When used in combination with artificial tears in the treatment of “dry eye” of diverse etiology; OR

5. Covered for members for whom corneal transplant surgery is the only alternative treatment option available for: a. Keratoconus b. Corneal transplants in which the healing resulted in warpage of the graft and abnormal astigmatism c. Scars due to injury, dystrophies or degenerative diseases;

   OR

6. The member has impaired vision, requires medically necessary vision correction AND conventional glasses or conventional contact lenses are insufficient AND the scleral lens significantly improves vision.

4

II. Replacement lenses

B. Replacement lenses are considered medically necessary under the members specific medical plans if covered because of a change in the patient's physical condition (not including refractive changes).

C. Charges to replace contact lenses that are lost, damaged, or required solely due to refractive changes are not covered under medical plan

III. Hard, soft or gas-permeable lenses may also be considered MEDICALLY NECESSARY for the following indications for Medicaid line of business:

A. Anisometropia of more than 3.00D; OR

B. Greater than 7.00D of myopia or hyperopia.

Policy Guidelines and Definitions

Definitions:  Corneal Contact Lens/Liquid Bandage: A fluid-ventilated, oxygen-permeable lens that vaults over the cornea and helps manage ocular surface disease. Used for post cataract surgery with intraocular lenses (IOL), treatment of aphakia, keratoconus, moisture barrier (for keratitis, corneal edema, dry eyes).  Prose (Prosthetic Replacement Ocular Surface Ecosystem) Lens: Scleral contact lens for complex corneal conditions including dry eye disease (DED).  Scleral Contact Lens (CPT-92317): A large diameter rigid gas permeable lens that rests on the sclera and creates a tear-filled vault over the cornea. Used for treatment of reddened eyes that are shrunken by inflammatory disease or sightlessness, dry eyes.  Scleral Shell or Shield: (Catchall term for different types of hard scleral contact lenses) fits over the entire exposed surface of the eye underneath the eyelids. It functions as a protective barrier against tear evaporation. Used as an artificial support and a protective covering for diseased eye or sightless or shrunken eye.  Therapeutic Soft Hydrophilic Contact Lenses are made of poly-2-hydroxyethyl methacrylate and other flexible plastics.
 Sclera: Clear covering over white of the eye.  Cornea: Clear covering over pupil and iris.  Epithelium: Layer of tissue that covers the cornea and conjunctiva. (Regenerates every 3-10 days in healthy eyes and damaged eyes in ocular surface disease, treatment is dependent on the cause.)

5

 Absorptive Contact Lenses: Tinted lenses that are used to improve a member’s visual clarity. This is done by reducing glare and increasing contrast. The percentage refers to the amount of light passing through the lens. See reference below for additional information.  Gas Permeable Scleral Lenses: Rigid lenses made of durable plastics that allow oxygen to pass through the lens. Lenses also are called GP lenses, rigid gas permeable lenses, RGP lenses and oxygen permeable lenses.

Coding Guidance

Code
Description
PA CPT Codes

92071 Fitting of contact lens for treatment of ocular surface disease No 92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia No 92311 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, 1 eye No 92312 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes, No 92313 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral No 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens both eyes except for aphakia No 92315 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, 1 eye No 92316 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes No 92317 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens No 92325 Modification of contact lens (separate procedure), with medical supervision of adaptation No 92326 Replacement of contact lens No HCPC Codes

S0515 Scleral lens, liquid bandage device, per lens (Commercial only) Yes S0590 Integral lens service, miscellaneous services reported separately Yes V2500 Contact lens, PMMA, spherical, per lens Yes V2501 Contact lens, PMMA, toric or prism ballast, per lens Yes V2503 Contact lens, PMMA, color vision deficiency, per lens Yes V2510 Contact lens, gas permeable, spherical, per lens Yes V2511 Contact lens, gas permeable, toric, prism ballast, per lens Yes V2512 Contact lens, gas permeable, bifocal, per lens Yes V2520 Contact lens, hydrophilic, spherical, per lens Yes V2521 Contact lens, hydrophilic, toric or prism ballast, per lens
Yes

6

Code
Description
PA V2522 Contact lens, hydrophilic, bifocal, per lens Yes V2599 Contact lens, other type Yes V2530 Contact lens, scleral, gas impermeable, per lens Yes V2531 Contact lens, scleral, gas permeable, per lens Yes V2627 Scleral cover shell Yes CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

National Coverage Determination (NCD) for scleral shell (80.5) NCD - Scleral Shell (80.5) (cms.gov)

National Coverage Determination (NCD) for hydrophilic lenses https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=233

The Medicare Benefit Policy Manual , Chapter 15, “Covered Medical and Other Health Services,” §100 and §120.

The Medicare Benefit Policy Manual , Chapter 16, “General Exclusions from Coverage,” §20 and §90.

Koppen, C., Kreps, E. O., Anthonissen, L., Van Hoey, M., Dhubhghaill, S. N., & Vermeulen, L. (2018, January). Scleral Lenses Reduce the Need for Corneal Transplants in Severe Keratoconus

https://www.ajo.com/article/S0002-9394(17)30453-1/fulltext

American Journal of Ophthalmology, Volume 185, Pages 43-47

Common Corneal Diseases-Corneal Diseases that may require a Transplant. (n.d.).

https://restoresight.org/cornea-donation/descriptions-of-diseases/

Eye Bank Association of America

Azman I. Custom scleral lenses and PVR PROSE. Treatment for post LASIK and RK complications, keratoconus, corneal transplants, and irregular corneas. Timonium, MD: Global Complex Eye Care; 2018. https://scleralcontacts.org/prose-treatment/ocular-conditions-prose-treatment/keratoconus-prose/ Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid- ventilated gas-permeable scleral contact lens. Am J Ophthalmol. 2000;130(1):33-41. Rosenthal P. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye Contact Lens. 005;31(3):130-134. Shepard DS, Razavi M, Stason WB, et al. Economic appraisal of the Boston Ocular Surface Prosthesis. Am J Ophthalmol. 2009;148(6):860-868.

7

Jedlicka, J., OD. (2018, August 20). Scleral GP contact lenses: How these can help you.

https://www.allaboutvision.com/contacts/scleral-lenses.htm

All About Vision

Basic Information of Absorptive Lenses from Open Access Journal of Ophthalmology, publish date July 20, 2018

https://medwinpublishers.com/OAJO/OAJO16000S1-003.pdf

Alexandro Rodriguez De Los Reyes, R , BostonSight PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) and Scleral Contact Lenses, American Academy of Ophthalmology

BostonSight PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) and Scleral Contact Lenses - EyeWiki (aao.org)

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/12/2007 Initial policy date 12/2023 Policy re-written no significant changes to coverage criteria. Added S0515, S0590 1/2024 Added Line of Business section 12/2024 Annual review with no changes

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.