Keratoconus often progresses to the point where eyeglasses alone aren't effective at correcting vision. At this point, doctors may prescribe large hard contact lenses called scleral lenses. These lenses flatten out the cornea to help you see better. Under Medicare, contact lenses are treated like eyeglasses and are typically not covered.
Full Answer
Are scleral contact lenses better for keratoconus?
In contrast to typical contact lenses, scleral contact lenses cover the entire cornea, which is why these are often more comfortable for people with cornea disorders (such as keratoconus). The National Keratoconus Foundation notes the following as three advantages of scleral contact lenses as compared to typical contact lenses:
Will insurance cover the cost of contact lenses for keratoconus?
The cost of contact lenses for keratoconus may or may not be fully covered, depending on your insurance policy. If you don't have health or medical insurance and you aren't covered by Medicare or Medicaid, financing companies that specialize in medical expenses offer plans where you can pay...
Does insurance cover scleral contact lenses?
Most insurance programs do not automatically cover the full cost of scleral contact lenses. In some cases, vision insurance may reduce the cost of your lenses and/or fitting fee. In other instances, contacting your medical insurance provider and inquiring what steps are necessary to obtain coverage can be helpful.
Can scleral lenses be used for other eye problems?
Scleral Contact Lenses For Other Eye Problems. In addition to keratoconus, scleral contact lenses can be used for eyes that have undergone a cornea transplant, and for people with severe dry eyes caused by conditions such as Sjogren's syndrome, graft-versus-host disease (GVHD) and Stevens-Johnson syndrome.
Are scleral lenses considered medically necessary?
Scleral contact lenses are the most common medically necessary contact lens treatment used; however, SynergEyes hybrid contact lenses are also commonly used. Here is a list of the most common conditions treated with medically necessary contacts; keratoconus.
Does Medicare cover a scleral shell?
Coding Guidelines Trial scleral cover shells are not separately payable. They are included in the allowance for scleral cover shells, V2627.
Are scleral contact lenses covered by insurance?
Does Insurance Cover The Costs Of Scleral Lenses? Scleral lenses are not automatically covered by vision or medical insurance. Though most insurances will reimburse the costs for scleral lenses when medically necessary, the rates and restrictions tend to vary greatly from one vision insurance provider to the next.
Does Medicare cover medically necessary contact lens?
While Medicare covers some vision services, it doesn't usually pay for eye exams or contact lenses. Some of the vision services original Medicare (parts A and B) may cover include: annual glaucoma test for people at high risk (including those with diabetes or a family history of glaucoma)
Which Medicare Part provides coverage for artificial eyes?
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. covers artificial limbs and eyes when your doctor orders them.
Does Medicare pay for a prosthesis?
For Medicare to pay for your prosthetic device, you must go to a Medicare-enrolled supplier. This is true no matter who submits the claim (you or the provider). Either Part A or Part B covers a surgically implanted prosthetic device depending on if the surgery takes place in an inpatient or outpatient setting.
How much does scleral lenses cost?
Including all appointments, these lenses cost $1200-2000, including fit and examinations, depending on their complexity. They provide a comfortable solution to vision correction not available in the past for more complicated conditions.
Is keratoconus considered a medical condition?
Keratoconus is an eye disease that affects the structure of the cornea, resulting in loss of vision. Keratoconus occurs in approximately one in 2,000 individuals, typically beginning in puberty and progressing into the mid-30s.
How long do scleral lenses last?
Patients can expect their scleral lenses to last about the same length as other rigid lenses, which is anywhere between 1 and 3 years. The longevity of your lenses depends on a few factors, like: If lenses are carefully handled and kept clean. If lenses remain properly-fitted, comfortable, and provide clear vision.
How do I bill for keratoconus?
CPT 92025 (Computerized corneal topography) applies. Coverage is usually present with keratoconus, irregular astigmatism or after trauma or corneal transplant as the diagnosis.
Does EyeMed cover keratoconus?
While it is true that many VSP and EyeMed plans can provide significant coverage for specialty contact lens care for keratoconus, this only applies to group policies purchased through an employer.
What makes a procedure medically necessary?
Medicare defines “medically necessary” as health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
Types of Scleral Contact Lenses
Scleral contacts are noticeably larger than standard gas permeable (GP) contacts and have a diameter equal to or greater than that of soft contact...
Scleral Contact Lenses For Keratoconus
Many optometrists and ophthalmologists recommend scleral contact lenses for a variety of hard-to-fit eyes, including eyes with keratoconus.In cases...
Scleral Contact Lenses For Other Eye Problems
In addition to keratoconus, scleral contact lenses can be used for eyes that have undergone a cornea transplant, and for people with severe dry eye...
Special-Effect Scleral Contacts
Sometimes the term "scleral lenses" (or "sclera lenses") also is used to describe special-effect contact lenses that dramatically alter the appeara...
Scleral Contact Lens Cost
Scleral contact lenses are custom-made for each wearer, so fitting scleral contacts demands greater expertise and more time than fitting standard s...
Does Medicare Cover Keratoconus?
Medicare is likely to cover some expenses related to the diagnosis and treatment of keratoconus but may not cover others. Typically, doctors begin to diagnose keratoconus during slit lamp examinations performed as a part of routine visits. Original Medicare generally doesn't cover this service, as it falls under vision care.
Does Medicare Cover Eyeglasses for Keratoconus?
Often, doctors begin treating keratoconus with prescription eyeglasses. Normally, Medicare treats eyeglasses as a non-covered expense. Exceptions are made for people who are undergoing cataract surgery, but no carve-out exists for people who need eyewear for keratoconus.
Does Medicare Cover Scleral Lenses for Keratoconus?
Keratoconus often progresses to the point where eyeglasses alone aren't effective at correcting vision. At this point, doctors may prescribe large hard contact lenses called scleral lenses. These lenses flatten out the cornea to help you see better. Under Medicare, contact lenses are treated like eyeglasses and are typically not covered.
Does Medicare Cover Corneal Cross-Linking for Keratoconus?
For intermediate-stage keratoconus, doctors may use corneal collagen cross-linking or CXL as a treatment. During this in-office procedure, a doctor applies vitamin B solution and shines ultraviolet light into your eye for up to 30 minutes.
Does Medicare Cover Corneal Rings for Keratoconus?
When keratoconus progresses to advanced stages, corneal rings are sometimes used to treat the condition. These small C-shaped plastic rings sit over the cornea, exerting pressure that flattens the surface to promote clearer vision. The journal Ophthalmology Management reports that Medicare Part B may sometimes cover corneal rings.
Does Medicare Cover Corneal Transplant for Keratoconus?
If all other treatments fail, your doctor may suggest a corneal transplant. During this surgical procedure, your damaged cornea is removed and replaced with a healthy donor cornea. Medicare often covers corneal transplants that are deemed medically necessary and performed in an approved facility. Usually, the coverage falls under Medicare Part B.
How Much Will I Pay for Covered Keratoconus Expenses Under Medicare Part B?
If Medicare Part B covers any diagnostic test or treatment for keratoconus, your plan will typically pay for 80% of the cost, leaving you responsible for the 20% that remains. Medicare supplement (Medigap) plans may help you pay for all or some of the out-of-pocket costs. Before Medicare Part B pays for expenses, you must satisfy your deductible.
How much does a scleral lens cost?
While not typical, in cases when a complex, highly customized scleral lens is required, cost can be as high as $4,000 per eye or more.
What is a scleral lens?
Sometimes the term "scleral lenses" (or "sclera lenses") also is used to describe special-effect contact lenses that dramatically alter the appearance of the wearer's eyes. However, these costume contact lenses (also called theatrical contact lenses, Halloween contacts or gothic lenses) typically are soft lenses that bear little resemblance ...
How big is the cornea?
The average human cornea is approximately 11.8 millimeters in diameter, so even the smallest scleral contacts are designed to cover the entire corneal surface. In comparison, most conventional GP contact lenses are 9.0 to 9.5 mm in diameter and cover only 75 to 80 percent of the cornea. Another category of gas permeable lenses bridges ...
Why are scleral lenses used?
Because scleral lenses are designed to vault the corneal surface and rest on the less sensitive surface of the sclera , these lenses often are more comfortable for a person with keratoconus. Also, scleral lenses are designed to fit with little or no lens movement during blinks, making them more stable on the eye, ...
How big are scleral contacts?
Scleral contacts are noticeably larger than standard gas permeable (GP) contacts and have a diameter equal to or greater than that of soft contact lenses. The smallest sclerals are approximately 14.5 mm in diameter, and the largest can be up to 24 mm.
What is the space between the cornea and the back surface of a scleral lens?
Also, the space between the cornea and the back surface of a scleral lens acts as a fluid reservoir to provide comfort for people with severe dry eyes who otherwise could not tolerate contact lens wear.
Why do people use corneal scleral lenses?
They also are frequently used when contact lenses are needed after LASIK or other corneal refractive surgery to correct irregular astigmatism. The size of lens used often is determined by the degree of complexity of the condition. ...
How much does keratoconus surgery cost?
If you require a corneal transplant, this procedure alone can cost from $13,000 to nearly $28,000, depending on the type of surgery and whether it's performed on an outpatient basis or involves a hospital stay.
Does insurance cover keratoconus?
Thankfully, most costs associated with keratoconus usually are covered by health or medical insurance. In particular, medical insurance typically covers most of the cost of corneal cross-linking or major keratoconus surgery (less deductibles and copays determined by your policy).
Is keratoconus covered by Medicare?
The cost of contact lenses for keratoconus may or may not be fully covered, depending on your insurance policy. If you don't have health or medical insurance and you aren't covered by Medicare or Medicaid, financing companies that specialize in medical expenses offer plans where you can pay for costs associated with keratoconus treatment ...
Work Credits and Receipt of SSDI
In order to qualify for SSDI as someone who is legally blind and under age 65, a work credit calculation is made by the Centers for Medicare and Medicaid Services ( CMS); this is based on the dollar amount of earnings in a job (or self-employment) in which you paid Social Security taxes (along with the total number of years worked).
What is the Difference Between Medicare Part A and Part B?
Medicare Part A covers hospitalization (and at 80 percent of the total cost). Meanwhile, Medicare Part B covers healthcare provided outside of a hospital, such as outpatient physician visits.
What is Medicare Supplemental Insurance or Medigap?
Medicare supplemental insurance (Medigap) is private insurance that can cover the remaining 20 percent of healthcare costs not covered by Parts A or B of Medicare. Some Medigap plans also include vision coverage (for routine exams and eyewear) which is not typically covered by Medicare.
Why a Corneal Transplant Can Be Needed
A corneal transplant in a keratoconus-afflicted person is typically recommended as a last resort when the cornea abnormality is causing persistent eye pain, and/or to restore vision when no other intervention has improved eyesight.
Difference Between Typical Contact Lenses and Scleral Lenses
Placed over the lens of each eye, typical contact lenses float on the tear film on the surface of the eye (per the American Academy of Ophthalmology ). Therefore, both soft and “hard” lenses rest on the cornea.
Option Number 1 – Corneo-Scleral or Semi-Scleral Lenses
This type of scleral lens rests near the junction between the cornea and the sclera, and covers a smaller portion of the sclera than occurs with full scleral lenses. Corneo-scleral (semi-scleral) lenses also typically have a smaller tear reservoir than full scleral lenses.
Option Number 2 – Mini-Scleral Lenses
In contrast to other scleral lens types, mini-scleral lenses vault over the entire surface of the cornea, and rest on the anterior sclera. An article in Clinical Ophthalmology reported that mini-scleral lenses often have a diameter between 15-18 mm. Therefore, mini-scleral lenses have less corneal clearance than other scleral lenses.
Option Number 3 – Full Scleral Lenses
These are the largest of the three types of scleral lenses, and provide the greatest amount of clearance between the back surface of the contact lens and the cornea. Similar to semi-scleral and mini-scleral contact lenses, these require filling the bowl of the lens with a saline solution prior to insertion in the eye.