Insurance & Scleral Lenses: Codes, Coverage, and Appeals

Insurance & Scleral Lenses: Codes, Coverage, and Appeals

Scleral lenses are, in many ways, the haute couture of contact lenses: meticulously designed, custom fitted, and transformative beyond expectation. For patients with keratoconus, severe dry eye, post-surgical corneas, or ocular surface disease, they are not a luxury—they are liberation.

Yet if scleral lenses are elegant, insurance can feel… baroque.

At University Optometric Center, we believe understanding your benefits should not require a minor in medical billing. Let us demystify the essentials: billing codes, coverage pathways, and the art of the appeal.

When Are Scleral Lenses Covered?

Insurance coverage for scleral lenses depends largely on one question: Are they medically necessary?

For patients diagnosed with conditions such as keratoconus, corneal ectasia, pellucid marginal degeneration, or severe ocular surface disease, scleral lenses are often classified as medically necessary contact lenses. In these cases, medical insurance—not vision insurance—may provide partial or full coverage.

Routine refractive correction (simple nearsightedness or farsightedness) is typically covered under vision plans, but scleral lenses prescribed for complex corneal conditions frequently fall under medical benefits.

The distinction matters. A great deal.

The Codes That Matter

Behind every claim lies a series of billing codes that communicate the “why” and “what” to your insurance carrier. While the specifics vary, here are the categories most commonly involved:
 

• CPT codes (Current Procedural Terminology): These describe professional services, such as the fitting and evaluation of contact lenses for medical conditions.

• HCPCS codes (Healthcare Common Procedure Coding System): These often describe the lens materials themselves, particularly when considered medically necessary durable medical equipment.

• ICD-10 diagnosis codes: These specify the underlying medical condition—keratoconus, corneal scarring, severe dry eye disease, and so forth.

Proper coding is not merely administrative housekeeping; it is the difference between a smooth approval and a perplexing denial.

Our team carefully documents corneal topography, visual acuity improvements, prior treatment failures, and medical necessity rationale to support each claim. Precision in documentation is just as vital as precision in lens design.

Understanding Coverage Limitations

Even when deemed medically necessary, coverage may include:
 

• Deductibles that must be met

• Coinsurance percentages

• Frequency limitations

• Preauthorization requirements
   

Some plans cover the fitting but not the lenses. Others reimburse only after upfront payment. A few require documentation of failed conventional contact lenses before approving scleral designs.
 

Yes, it can feel like choreography. But it is choreography we know well.
 

The Art of the Appeal

A denied claim is not a final verdict. It is, quite often, an invitation to elaborate.
 

Appeals are most successful when they include:
 

• A letter of medical necessity from your optometrist
• Supporting diagnostic data (corneal maps, clinical findings, visual acuity comparisons)
• Documentation of prior treatments and outcomes
• Peer-reviewed literature supporting scleral lens efficacy for the condition
   

In essence, the appeal reframes the conversation: this is not elective eyewear; this is essential medical care.

At University Optometric Center, we guide patients through this process with strategic clarity. We understand insurer language, submission timelines, and how to construct a compelling narrative rooted in medical evidence.

A Partnership in Clarity

Scleral lenses restore more than vision. They restore confidence, comfort, and continuity of daily life. Insurance, though complex, is navigable with the right advocacy and expertise.

Our philosophy is simple: patients should focus on seeing beautifully—not deciphering policy fine print.

If you are considering scleral lenses or have encountered an insurance obstacle, allow us to illuminate the path forward. With careful documentation, proper coding, and thoughtful appeals when necessary, coverage becomes less mysterious and far more manageable.

Because when vision is medically essential, persistence—and precision—are entirely justified.

Contact our office in Irvine or Newport Beach at (949)-854-7122 or (949) 476-2870 to book an appointment.