The Plan

Members with certain conditions affecting the eye may be eligible for eyeglasses or contact lenses as a medical benefit when medical necessity criteria are met. Contact lenses are soft gel-like or hard lenses that are placed directly on the eye. They are commonly used to correct refractive vision errors such as near- or far-sightedness, but can also be used for therapeutic indications to aid in the treatment of various diseases affecting the eyes. Eyeglasses are worn externally and can also be used to correct certain ophthalmic conditions. Both eyeglasses and contact lenses come in a number of different materials for specific indications. The Plan considers contact lenses or eyeglasses for specific ophthalmic diseases medically necessary. The Plan does not consider glasses or contact lenses for common vision conditions such as refractive error as medically necessary under the medical benefit.

Definitions

• Soft Contact Lenses are common, everyday lenses accounting for the majority of all prescribed lenses. They are made of a gel-like material that covers the cornea only, and used to treat common vision conditions as described below.
• Scleral Shell Contact Lenses are a hard-shell type of lens that are worn over a larger area than a typical soft contact lens. They can be specifically designed to match irregularities on a patient's eye and painted or designed to address cosmetic and functional deficits.
• Intraocular Lenses are artificial implants used to replace the natural lens for conditions such as cataracts, congenital aphakia, or injury.
• Hydrophilic Contact Lenses, also known as Corneal Bandages, are soft protective lenses placed over the cornea. They are used to treat conditions where the cornea needs to be protected from the mechanical trauma of the eyelid rubbing across it to allow for healing.
• Cornea refers to the transparent membrane on the front part of the eye. A number of disorders can affect this structure.
• Lens of the human eye is a small transparent structure in the anterior eye that can be stretched by muscles of the eye to change the focusing power of vision.
• Aphakia is the absence of the lens of the eye, which can be from surgical removal (cataract surgery), perforating wound or ulcer, or congenital absence. Loss of the lens causes inability for the eye to change focus.
• Pseudophakia is a condition in which the natural lens of the eye has been removed and replaced by an intraocular lens; pseudophakia indicates a member has undergone cataract surgery.
• Keratoconus is a condition where the cornea of the eye has an irregular shape or cone-shaped bulge.
• Keratoconjunctivitis Sicca is a condition of dry eyes that can occur alone or in conjunction with a number of local and systemic diseases.
• Aniridia is the absence of the iris of the eye, which is the colored part of the eye surrounding the pupil. Aniridia can be caused by a congenital absence in one or both eyes, or by penetrating trauma or injury.
• Anisometropia refers to when the eyes have different refractive power and unequal focus between the eyes. Some difference is accountable with normal physiology, but a difference of two diopters or more is considered anisometropia.
• Pathological Myopia is a condition of nearsightedness that is so severe it causes an alteration in the shape of the eye, and is a leading cause of legal blindness. This condition is also known as degenerative myopia.
• Aniseikonia is a condition where images appear different sizes when viewed from each eye individually. Uncorrected, it can cause balance problems, eyestrain, and headache.
• Irregular Astigmatism is a condition where abnormal shaping of the cornea, often from injury, scarring, or congenital malformations, causes distortion of the perceived image. It differs from regular astigmatism which is a minor refractive distortion in the lens of the eye. Keratoconus is a leading cause of irregular astigmatism.
• Common Vision Conditions is a term that is used here to define common visual deficits including but not limited to:
  • Nearsightedness: when a person can see objects up close but more distant things may appear distorted or blurry
  • Farsightedness: when a person can see objects far away but closer things may appear distorted or blurry
  • Astigmatism: when the lens of the eye is not perfectly shaped, resulting in some distortion of visual images
  • Presbyopia: farsightedness caused by loss of the elasticity of the lens, typically associated with aging, that decreases the ability to change focus.

Clinical Indications

Scleral Shell Contact Lenses

The Plan considers scleral shell contact lenses medically necessary for members, (up to 2 contact lenses per eye, per benefit period) with at least ONE of the following criteria:

1. Severe dry eyes, such as that resulting from:
   • Sjogren's disease
   • Chronic graft-versus-host disease
   • The effects of radiation
   • The effects of prior surgery
   • Meibomian gland deficiency; or
2. Symptomatic moderate or severe dry eye disease after trial and failure of topical, systemic, or procedural management:
   • Two or more of the below:
     1. LFA-1 antagonists (e.g., lifitegrast)
     2. Non-corticosteroid immunomodulatory agents (e.g. Cyclosporine)
     3. Oral macrolide and/or tetracycline antibiotics
     4. Preservative-Free Artificial Tears or inability to afford continuous medical non-tear supplements
     5. Punctal occlusion
     6. Topical secretagogues; or
3. To support orbital tissue when the eye is sightless or shrunken by injury, congenital condition, or autoimmune/inflammatory disease; or
4. Corneal ectatic disease, including but not limited to the following:
   • Keratoconus
   • Keratoglobus
   • Pellucid marginal degeneration
   • Post-LASIK ectasia
   • Terrien’s marginal degeneration; or
5. Irregular corneal astigmatism with two (+ or -) diopters of irregular astigmatism present in either eye; or
6. Severe ocular surface disease, such as that resulting from:
   • Steven-Johnsons Syndrome (SJS) or Toxic Epidermal Necrolysis syndrome (TENS)

7. Replacement of scleral shell lenses is considered medically necessary when there is a change in condition or ongoing need as documented by the treating physician. Replacement is not covered for refractive changes or if lost or damaged.

Hydrophilic Contact Lenses (Corneal Bandage)

The Plan considers hydrophilic contact lenses medically necessary in members, (up to 2 contact lenses per eye, per benefit period) with at least ONE of the following criteria:

1. Severe dry eyes, such as that resulting from:
   • Sjogren's disease
   • Chronic graft-versus-host disease
   • The effects of radiation
   • The effects of prior surgery
   • Meibomian gland deficiency;
2. Corneal diseases associated with systemic autoimmune disorders; including but not limited to the following conditions:
   • Rheumatoid arthritis
   • Epidermal dysplasia
   • Epidermolysis bullosa
   • Atopic dermatitis
3. Corneal exposure from cranial nerve 7 dysfunction or other anatomic or paralytic abnormality preventing closure of the eyelid; or
4. Corneal or limbal stem cell deficiency, including but not limited to damage resulting from:
   • Steven-Johnsons Syndrome (SJS) or Toxic Epidermal Necrolysis syndrome (TENS)
   • Chemical or thermal ocular injury
   • Surgical procedures
   • Iatrogenic or accidental injury
   • Aniridia (congenital or acquired)
   • Ocular pemphigoid
   • Idiopathic corneal stem cell deficiency
5. Neurotrophic corneal conditions, including but not limited as a result of the following:
   • Surgical intervention
   • Trigeminal ganglionectomy or rhizotomy
   • Herpes simplex or zoster of the cornea
   • Congenital corneal anesthesia
   • Keratitis
   • Recurrent corneal ulceration.

Replacement of hydrophilic lenses is considered medically necessary when there is a change in condition or ongoing need as documented by the treating physician. Replacement is not considered medically necessary for refractive changes or if lost or damaged.

Contact Lenses and Eyeglasses for Aphakia

Medically Necessary Criteria for Initial Authorization

The Plan considers contact lenses or eyeglasses medically necessary for members with congenital or acquired aphakia, such as after cataract surgery. If a member has cataract surgery, the request for eyewear must be within 1 year of the surgery.

The following may be eligible for aphakic members WITHOUT intraocular lens:

1. One pair of bifocal eyeglasses; or
2. One pair of eyeglasses for far or near vision; or
3. Contact lenses for far vision: Unless otherwise indicated by the prescriber, the Plan considers up to six aphakic contact lenses per eye (including fitting and dispensing) medically necessary per calendar year; or
4. A combination of contact lenses and/or one pair of near/far eyeglasses to simulate bifocal eye function; and/or
5. The following may also be considered medically necessary for patients receiving prosthetic eyeglasses or contacts for aphakia:
   • UV coating
   • Cataract sunglasses (tinted lenses)
   • Impact resistant material (e.g., polycarbonate, Trivex) is considered medically necessary ONLY in members with only one functional eye

The following may be eligible for aphakic members WITH intraocular lens:

1. One pair of bifocal eyeglasses; or
2. One pair of eyeglasses for far or near vision; or
3. One pair of contact lenses for far vision; or
4. A combination of one pair of contact lenses and/or one pair of near/far eyeglasses to simulate bifocal eye function; and/or
5. The following may also be considered medically necessary for patients receiving prosthetic eyeglasses or contacts for aphakia:
   • UV coating
   • Cataract sunglasses (tinted lenses)
   • Impact resistant material (e.g., polycarbonate, Trivex) is considered medically necessary ONLY in members with only one functional eye

Medical Necessity Criteria for Reauthorization

For post-cataract surgery WITHOUT intraocular lens:

1. For eyeglasses, an additional request is considered medically necessary when there is a change in condition or ongoing need as documented by the treating physician for members; or
2. For contact lenses, up to six aphakic contact lenses per eye per benefit period (annually) are allowed; or
3. Replacement of contact lenses or eyeglasses are not considered medically necessary if lost or damaged.

For post-cataract surgery WITH intraocular lens:

1. Additional pairs of prescription eyeglasses and contact lenses are not considered medically necessary; and/or
2. Replacement of contact lenses or eyeglasses are not considered medically necessary if lost or damaged.

Associated Services

When the member meets criteria outlined above for contact lenses or eyeglasses, the following services may be considered medically necessary:

1. General examination
2. Refractive examination
3. Advanced corneal topographic modeling
4. Prescription

Fitting of contact lenses or scleral lenses

Experimental or Investigational / Not Medically Necessary

The following accessories or modifications to eyeglasses and contact lenses are NOT considered medically necessary by the Plan as a medical benefit:

• Glasses cases
• Contact solution
• Mirror coating
• Polarization
• Progressive lenses
• Scratch resistant coating
• Tinted or colored lenses
• Anti-reflective coatings
• Oversized eyeglasses
• Designer frames
• Colored contact lenses
• Any other accessory or modification designed for cosmetic purposes

Contact lenses and eyeglasses, regardless of the type or material, and associated services are NOT considered medically necessary by the Plan as a medical benefit for the following indications:

• Nearsightedness
• Farsightedness
• Presbyopia
• Astigmatism, except as specifically defined in the medical necessity criteria above