Do you qualify for medically necessary contact lenses? Most of the time, contact lenses are considered a “cosmetic” vision correction device. However, in some conditions, contact lenses can provide far superior visual results than eyeglasses. Medical and Vision insurance companies recognize this, and will cover the custom fitting of specialized contact lenses as a medical necessity in some cases.

In order to qualify for the medical insurance benefit for your contact lenses (note: this is a separate benefit from your vision insurance benefit), your prescription contacts must be seen as medically necessary and visually superior to eyeglasses in order to correct your vision.

Prescriptions for Medically Necessary Contact Lenses

Certain medical conditions cannot be addressed sufficiently through surgery or glasses and require special contact lenses in order to treat the patient’s vision issues. The conditions listed below are some of the diagnoses considered “medically necessary” where the use of customized contact lenses is the best treatment option.

  • Keratoconus
  • Anisometrophia
  • Aphakia

(see definitions below)

Keratoconus is a condition characterized by a progressive deformation of the cornea. The irregular corneal shape distorts the optics of the eye similar to the way a warped eyeglass lens would. Rather than exhibiting the smooth curvature expected of a healthy cornea, keratoconus is caused by variable areas of steepening located throughout the tissue. Keratoconus varies in severity among individuals, ranging from very mild to extreme visual distortion. It typically affects both eyes, but in an asymmetric fashion—one eye is nearly always warped and “cone shaped” more severely than the other.

keratoconus

While keratoconus may cause nothing more than a minute, bland distortion to the patient’s vision that is nearly imperceptible without bothering the individual, in the majority of cases the visual distortion ultimately requires the use of specialized rigid gas permeable contact lenses (RGPs). RGPs effectively compensate for the corneal warpage, allowing the individual to lead a normal life. In severe cases of keratoconus, the corneal warpage may progress beyond even what an RGP can address and corneal transplantation may be required.

Anisometrophia is a condition in which the patient’s two eyes have drastically different refraction powers (prescriptions). In other words, one eye has much poorer quality of vision than the other eye. Typically, most of the differences in refraction between a patient’s two eyes can be corrected with glasses or contact lenses. If anisometropia has caused amblyopia (or “lazy eye”) in a child, then treatment may include patching or drops to help correct the condition. Amblyopia is caused when the brain actually favors the vision in the “good eye” over that of the “bad eye,” resulting in the disuse of the worse eye. Studies have shown that some degree of amblyopia affects one out of every 40 children. Due to the possibility of eye position imbalances when using prescription glasses to correct anisometrophia, the most common recommendation from the optometrist is to correct the condition with contact lenses.

lensAphakia is the removal or absence of the lens of the eye(s) due to surgery, trauma (perforation injury, ulcer, or other trauma), or other ocular abnormality. An aphakic eye is usually severely out of focus and requires a powerful lens in order for the person to have clear vision. To avoid any undue magnification and/or distortion that may be caused by glasses, such a lens may be prescribed as medically-necessary. In extreme cases, a lens surgically implanted within the eye may be considered a feasible option as well.

Medical Insurance Benefits

Usually, the medically necessary contact lens benefit is greater than the elective contact lens benefit, and some vision plans will pay a benefit for medically necessary contacts even if the plan does not have elective contact lens coverage. At Primary Eyecare, our most common diagnosis for medically necessary contact lenses is a patient with high levels of myopia (over -10.00D) or high farsightedness (over +10.00D). If you have questions regarding your eligibility for medically necessary contact lenses, please don’t hesitate to contact us. We will be happy to discuss your options as we strive to provide you with the best patient experience and your best possible vision!