Medically Necessary Contact Lenses

Having trouble seeing a future past your vision problems?

For some patients, their vision cannot be corrected with glasses. Most contact lens wearers think their contact lenses feel “visually” or “medically” necessary. However, “medically necessary contact lenses” are prescribed to provide vision that is better than glasses or soft contact lenses. To put things in perspective, some patients cannot see anything on the letter chart even with glasses or soft contact lenses. These patients usually face two options: undergo invasive surgery such as corneal transplantation or find the best available custom contact lens correction.

Medically necessary contact lenses are prescribed to provide vision superior to glasses or soft contact lenses.

Who is a candidate for medically necessary contact lenses?

High Prescriptions

The higher the prescription in glasses, the quality of vision provided by your glasses can begin to decrease. If you have high enough glasses prescription, you may be a candidate for special contact lens benefits. We call this high ametropia. Some insurance companies offer extra coverage in these cases, but they generally require prescriptions over 10.00 diopters. Sometimes, people have a larger difference between the prescription in each eye, which compromises the quality and size of the images that are seen. This is called high aniosmetropia and insurance companies offering this coverage require a difference of 3.00 diopters between each eye.

Irregular Corneas

The cornea, the front surface of the eye, or the clear window we look through to see the world. This structure needs to be a smooth, regular surface; otherwise the world is seen as distorted. There are corneal irregularities, such as Keratoconus or Pellucid Marginal Degeneration, which lead to a warping of the cornea.

Corneal surgeries – such as corneal transplants – can also result in an irregular corneal surface. In some cases, corneal scarring can warp and distort the vision. Patients with these conditions tend to have “hard-to-fit” eyes or struggled with soft contact lenses, and therefore benefit the most dramatically from medically necessary contact lenses.

These people tend to be ineligible for unrestricted driving privileges. The use of medically necessary contact lenses can decrease glare, improve warped vision and improve visual acuity from an average best corrected vision of 20/70 to an average of 20/32 (Severinsky, 2010). With the lens, these patients become eligible for normal DMV driving licenses.

Ocular Surface Diseases

Uses for medically necessary contact lenses include the treatment of severe dry eye disease and eye discomfort. Scleral contact lenses (see below for details) can provide a new “environment” for the very dry, uncomfortable eyes. People that would most benefit from scleral contact lenses are people with rheumatological diseases (such as Rheumatoid Arthritis or Sjogren’s syndrome) or ocular graft versus host disease.

Someone with dry eye disease typically lacks a proper tear film (the eye’s source of lubrication), which leads to friction across the highly sensitive cornea every time think blink. Scleral contact lenses combat this by providing a constant source of fluid to the eye while protecting the eye from the blinking eyelids. PScleral lens wearers report that their life has significantly improved with the use of these lens. Their feedback has been characterized by a marked relief of eye discomfort and overall improvement in daily life (Segal, et.al., 2003)(Romero-Rangel, et.al., 2000).

What are the different types of medically necessary contact lenses?

Soft contact lenses

– In the realm of medically necessary contact lens indications, most patients don’t get their best visual benefit from soft contact lenses. A soft contact lens typically drapes the eye like a wet blanket, instead of providing crisp vision. For those who utilize this type of lens, conventional (or off-the-shelf) lenses can be prescribed or we can custom order almost any prescription needed.

Hybrid contact lenses

This is a covalently bonded soft and hard material that provides the visual benefits of a hard contact lens with the comfort of a soft contact lens.

Gas permeable contact lenses

This is a hard, oxygen permeable material that provides crisp optics to a distorted cornea. These lenses can range in size and shape, but conventionally they are smaller in size and easy to handle than soft lenses. Soft contact lenses tend to be more comfortable and easy to get used to than gas permeable contact lenses.

Scleral contact lenses

This is a type of gas permeable contact lens that provides crisp optics but has a huge advantage of the comfort of a soft contact lens. This lens is more of a prosthetic device, since it does not come in contact with the cornea. Instead, it vaults over the cornea and sits on the scleral (or white of the eye). While that might sound unusual, these lenses offer the maximum benefit for those suffering from refractive and surface eye complications.

What does insurance typically cover and what are the general costs associated?

Patients who pursue medical contact lenses are not getting these lenses for a cosmetic purpose, but rather from a genuine need for vision and/or eye health. Regardless, medical insurance companies have such a vast scope of coverage (i.e. the whole body’s health) and often times they don’t understand the true need for “medically necessary” contact lenses. Thus, coverage isn’t always guaranteed.

The treatment of the irregular eye with medically necessary contact lenses tends to be a complex endeavor in which few doctors truly excel. This leads to higher associated fitting costs with these lenses. The material costs for the contact lenses range depending on the complexity of fit and type of contact lens prescribed, but they run in the ballpark of a year’s supply of high quality daily replacement contact lenses. However, these lenses have the potential to last longer than one year with proper maintenance.

References:
1. Schornack MM. Scleral lenses: a literature review. Eye Contact Lens 2015;41(1):3-11.
2. Severinsky B, Millodat M. Current applications and efficacy of scleral contact lenses – a retrospective study. Journal of Optometry 2010;3(3):158-163.
3. Segal O, Barkana, Y, Hourovitz D, et al. Scleral contact lenses may help where other modalities fail. Cornea 2003;22(4):308-310.
4. Romero-Rangel T, Stavrou P, Cotter J, et al. Gas-Permeable scleral contact lens therapy in ocular surface disease. Am J Ophthalmology 2000;130:25-32.
5. Why Do We Wear GP Contact Lenses? (n.d.). Retrieved May 02, 2017, from http://www.contactlenses.org/wearertest.htm
6. Scleral Lenses (n.d.). Retrieved May 02, 2017, from http://www.contactlenses.org/scleral.htm