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Medically Necessary Contact Lenses: Medical Plan or Vision Plan Responsibility?

Do you know how to work with insurance companies to achieve the biggest bang for your buck?
By Robert L. Davis, OD

6/15/2016

For those patients with certain medical conditions, contact lenses provide a distinct opportunity to improve patient quality of life in cases in which corneal shape is distorted or if a spectacle correction fails to provide adequate vision. Visual phenomena like glare, double vision and sensitivity to light can make processing images more difficult for patients; as such, in many cases non-elective procedures are the only solution to recapture a normal lifestyle. However, even when faced with the same procedures and diagnostic codes, each vision insurance company has its own guidelines to determine what constitutes a “medically necessary” contact lens. As such, the imbalance in coverage between vision insurance companies, coupled with rising health care costs, often means a policy nightmare for the eye care practitioner. 

Today, most medical plans are coupled with vision care plans, though many limit medical coverage for specialty services to just the diagnosis of the condition and coverage of the treatment. This creates a problem for patients seeking resolution for an ocular issue: they have covered access to the diagnostic services used to identify the condition and the actual medical devices (i.e., corrective lenses) necessary to treat the issue, but not the medical procedures (i.e., surgery and medical treatment) they may have to undergo to enable the treatment to work. Ultimately, for patients to benefit, the medical portion must be covered under both the vision care and medical care sides of an insurance plan.

Indications and Options
As specialty lenses are indicated primarily for patients with irregular corneas (e.g., in the case of keratoconus, pellucid marginal degeneration, scarring, post-surgical corneal abnormalities), gas permeable materials figure prominently in the approach to care. GPs provide a rigid surface that neutralizes the corneal irregularity, in effect replacing it with the controlled regular surface of the lens. Some conditions are better served by sclerals rather than corneal GP lenses due to their design with an elevated dome and haptic zone that vaults the cornea to land on the sclera, respectively. Hybrids that combine a GP center with a soft lens periphery may be also be possible to improve comfort while custom soft lenses may suffice for some patients.

Beyond irregular cornea indications, specialized custom contact lenses are typically also appropriate for most medically necessary criteria like:

• Binocular vision issues caused by the presence of nystagmus, anseikonia and anisometropia, as well as glare and light sensitivity resulting from aniridia and anisocoria. 

• High myopic or hyperopic prescriptions if visual improvement (as defined using Snellen acuity) with contact lenses surpasses that which is possible with spectacle wear. 

• Lens use following refractive surgery and other traumatic cases, in which improved visual acuity can be demonstrated with lens wear.

However, some disputes remain regarding insurance coverage. Though patients and/or health care providers may define a condition as medically necessary, guidelines for a specific health care plan may not agree. 

Consider, for example, the role of scleral lenses. The lens design includes a fluid compartment underneath the lens’s surface to keep the cornea hydrated; as such, these lenses are well-suited for the treatment of severe ocular surface diseases like corneal stem cell deficiency, Stevens-Johnson syndrome, chemical and thermal injuries to the eye, ocular pemphigoid, neurotrophic corneas, severe dry eye from Sjögren’s syndrome, chronic graft-versus-host disease, ocular radiation, corneal exposure and corneal disorders associated with systemic autoimmune diseases such as rheumatoid arthritis. The question is, however, whether these are medical conditions, or whether they covered under primary vision care. It often varies among providers.

Taking Responsibility
Most health care plans determine the criteria for their respective covered population. For example, contact lenses for masking irregular astigmatism associated with keratoconus and other corneal disorders requires certain documentation from the initial exam and follow-up visits to cover requests for coverage.1 Additionally, the patient’s first visit to the clinic must include a comprehensive eye exam, performance of advanced corneal topographic modeling or keratometry and documentation of the lens fitting process.1 Failure on the part of the practitioner to adhere to these criteria may lead to disqualification from reimbursement. 

Table 1 correlates the different covered conditions with corresponding vision care plans. Note that each offers different coverage for different conditions; uniformity is rare and should not be expected. As such, it is the responsibility of the practitioner to inform the insurance carrier of the needs of their patient population.

Table 1. A Comparison of Medically Necessary Contact Lens Vision Care Plans 
 ConditionEyeMedDavisVSPSuperiorHumanaSpectera
 Anisometropia3D in any meridian.≥4D BVA ≥20/40 intact epithelium.
3D4D and VA improves ≥20/60>3.5D with diplopia or with specs. Aesthenopia. >3.5D
 High Ametropia±-10D
 ±-8D±-10D
±-10D
±-10D
 
 KeratoconusNot correctable to 20/25. Two lines better than 20/25.K readings or topography BVA ≤20/40. Two lines improvement. Abscense of hydrops. Intact epithelium.K readings , OCT or topography.Topography or K readings and notes.Two lines improvement. With documentation. 
 Corneal EctasiaAchieve comfort and/or vision correction not possible with mid- to moderate keratoconus. Suitable for contact lens applications.     
 Vision ImprovementTwo lines better than specs.     
Aphakia BVA ≥20/100. APhakia without impant. No corneal or vitreous opacity. Intact macula. Intact epithelium.Included.Glasses provided together with contact lenses.Doctor must certify that contact lenses are medically necessary. 
Aniseikonia Unequal image size between the two eyes. Intermittent or constant diplopia. Less than 100 degrees steropsis. Intact epithelium.    
 Aniridia Surgical or traumatic.    
 Irregular Astigmatism ≥2D principle meridians are separated < 90 degrees. Two lines of improvement. BVA <20/70.
Included   
 Nystagmus  Included.   
 Corneal Transplant  Included.   
 Corneal Dystrophy  Included.   
 Colored Contact Lenses  For achromatopsia, albinism, aniridia, anisocoria or polycoria pupil abnormality.   

Because we live in an era where most doctors are held accountable for their actions—including and especially billing policies—proper documentation is the best way to guarantee passing an audit and receiving payment for the work provided. As such, the contact lens fitting, dispensing and follow-up visit must each be separately documented in the practice’s medical records, with a thorough record made of all services provided. This includes patient pick-up of a reordered contact lens prescription or other ancillary events that may occur later on. 

Typically, records should include the prescription, number and material type of contact lenses dispensed; patient lens wear and replacement schedule; recommended care and cleaning instructions; any data from the fitting appointment; visual acuity measurements taken both through the lenses and overrefraction; and the date the final lenses were dispensed. Additionally, practitioners should ensure they have a documented contact lens history on file. This should include information on the use and care of the patient’s lenses in their work environment; hobbies and daily routines; previous lens experience and any type of lens accoutrement used. 

The patient’s lens fit and evaluation appointment should include keratometry or topography, with proper diagnosis made if a corneal anomaly like corneal distortion or an ectatic disease is initially suspected. Recorded observations from a slit lamp should document both views with a diagnostic contact lens for the purpose of assessing fit and the patient’s eye sans-lens to assess the ocular health of the cornea, conjunctiva, sclera, tear film and eyelids. Overrefraction with the contact lenses should be recorded monocularly, with visual acuities noted for each trial lens tested, as well as the final contact lens prescription. A short narrative assessment of the patient’s subjective response and/or the doctor’s objective response regarding the state of the contact lens ordered should also be written; this should include comments on the clinical findings, impressions and diagnosis. 

Additionally, practitioners should add notes on their planned treatment plan to the patient’s file, with information like the contact lens materials and parameters included. Dispensing visit documentation should contain instructions prescribed to the patient for their lens care regime, handling and wear schedule. Finally, a description on the patient’s ability to apply and remove the contact lenses, as well as financial records relating to the ordering of the final lens prescription and a comment regarding whether the contact lenses were dispensed from stock for record-keeping purposes may also be prudent to include.

Records taken at follow-up appointments of the patient’s progress should document their positive and negative comments related to wearing the lens, as well as the patient’s report of their level of compliance with practitioner instructions. Notes on the patient’s advances in their lens wear should include monocular acuities and overrefraction as well as slit lamp observations documenting the lens on the cornea and the health of the corneal surface and surrounding tissues. Finally, any new clinical findings or changes in lens care, wearing or replacement recommendations should be written down for the purposes of updating treatment plan records. When documenting medical necessity, it may be useful to include pachymetry, specular microscopy, tear film assessment including osmolarity, InflammaDry scores, staining assessment with both NaFl and lissamine green, meniscus height, tear break-up time and the status of the meibomian glands.

Table 2 lists an example of one company’s (EyeMed) test requirements for provision of coverage to new and existing contact lens wearers. In comparison, other companies require itemized financial records for medically necessary contact lenses to include: patient name; date of service; contact lens brand, type, quantity and date dispensed; customary costs for services and materials; amount billed to the insurance, amount paid by the patient and method of payment.

 Table 2. EyeMed Insurance Coverage for Contact Lens Wearers
 TestNew WearerExisting Wearer
 Contact Lens-Related HistoryRequiredRequired
 Keratometry and/or Corneal TopographyRequiredRequired
 Anterior Segment Analysis with DyesAs IndicatedAs Indicated
Biomicroscopy of Eye and AdnexaRequiredRequired
 Biomicroscopy with Lens: Fluorescein Pattern (Rigid Lenses)
or Orb Movement and/or Centration (Soft Lenses)
RequiredRequired
 OverrefractionAs IndicatedAs Indicated
 Visual Acuity with Diagnostic LensesRequiredAs Indicated
 Determination of Contact Lens Specifications
Determined to Obtain the Final Prescription
As Indicated As Indicated
 Member Instructions and ConsultationsRequiredRequired
 Proper Documentation with Assessment and PlanRequired Required

Return to Base
Going back to the question at hand—whether medical care plans and vision care plans should make a greater effort to overlap coverage for the patient—a related point is this: even with dual coverage, many of the medically necessary treatments fall through the cracks because vision care plan providers and medical care plan providers believe the procedure in question is not in their sphere of coverage. As such, both practitioners and their patients are the ones to take the hit. However, we may have the ability to make a difference. 

First and foremost, we as practitioners must educate the medical plan coordinator as to the difference between a vision care expense and the need for coverage for a medical condition. If this need is not successfully communicated, the patient is left with the confusing scenario of not understanding why their medical condition is not covered by the vision care plan. Vision care plans should strive to provide a better environment for our patients, streamline the approval process and create improved billing efficacy for eye care providers to employ. Customizing the coverage of medically necessary contact lenses may also help insurance companies develop a competitive advantage for their products in the marketplace. Creating clear guidelines may also help develop a more uniform categorization system for practitioners to divide patients into, leading to improved efficiency of submission for reimbursement and a reduction in the costs associated with billing for services. 

Many industry watchers believe that separating the refraction tests from the medical eye health exam is coming in the future. The era of bundling services is a concept of the past. Each procedure will have its own billing code with corresponding payment. ICD-10 is the first attempt to breakout diagnostic codes, and procedure codes will be the next project CMS will attempt to streamline. With the consolidation of medical insurance companies in our immediate future, the trickle-down effect will soon reach the vision care plan providers with medical guidelines filtering into our vision insurance plans. Educating administrators with regards to the complete needs of our patients—both on the vision care side as well as the medical care side—will also allow patients that may not be aware of current options to receive the services they require.

H
ealth care insurance is an ever-evolving entity, and contact lens practitioners must remain informed of changes that impact the care we provide. We must remember that some medical conditions require contact lenses as a serious form of treatment. For some people, they are not simply a cosmetic option.

Dr. Davis practices in Oak Lawn, Ill., where he is the director of the contact lens clinic at Davis EyeCare. He is also a co-founder of EyeVis Eye and Vision Research Institute, where he works developing contact lens designs and furthering research on anterior segment pathophysiology. Dr. Davis has been recognized as a diplomate in the corneal, contact lens and refractive technology section of the American Academy of Optometry and is an inductee in the National Academy Practice in Optometry as well as an advisor to the Gas Permeable Lens Institute and a recipient of the Gas Permeable Practitioner of the Year Award. He has also been honored as one of the 50 most influential optometrists in 2015.

1. Aetna. Contact Lenses and Eyeglasses. Available at: www.aetna.com/cpb/medical/data/100_199/0126.html. Accessed February 3, 2016.



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