Aetna Contact Lenses Eyeglasses Coverage Update

Medical Necessity Criteria

Replacement Eyeglasses Under Plans With a Pediatric Vision Benefit

Replacement lenses are medically necessary for children/adolescents when ANY of the following are met:

ANY of the following

There is a change in refractive error
With regular use, the previous eyeglasses were broken or marred to a degree significantly interfering with vision or eye safety
Replacement because a different frame size or shape is necessary due to the child's growth, metal allergy or other justifiable medical reasons

Prosthetic Contact Lenses and Eyeglasses for Aphakia (Medicare & HMO)

For Aetna Medicare and HMO plans, external and intraocular lenses are considered medically necessary prostheses after cataract surgery when used to restore vision in aphakia. Covered when ALL of the following Medicare-aligned provisions apply:

ALL of the following

Member is aphakic following cataract surgery or congenital absence of the lens
Lenses are used to restore the vision provided by the crystalline lens (including bifocals, near/far spectacles, contact lenses for far vision and spectacles for near vision)
UV protection is medically necessary in lieu of regular lenses when applied to glass; anti-reflective coating, tints or oversize lenses are not generally considered medically necessary unless documented

Prosthetic Contact Lenses and Eyeglasses for Aphakia (Traditional/non-HMO plans)

Under traditional plans, contact lenses or eyeglasses may be considered medically necessary as prosthetics after cataract surgery when used in lieu of intraocular lenses.

ALL of the following

Member is aphakic after cataract surgery and the device is used as a prosthetic in lieu of an intraocular lens
First pair after cataract surgery is covered and additional pairs are covered each time the prescription changes

Therapeutic Hydrophilic Contact Lenses (Corneal Bandage)

Therapeutic soft (hydrophilic) contact lenses or gas-permeable fluid-ventilated scleral lenses are medically necessary when used as moist corneal bandages for severe ocular surface disease. Covered when ANY of the following indications are present:

ANY of the following

Corneal stem cell deficiency (e.g., Stevens-Johnson syndrome/TEN, chemical/thermal injuries, aniridia, idiopathic corneal stem cell deficiency, ocular pemphigoid)
Neurotrophic (anesthetic) corneas from acquired etiologies (e.g., acoustic neuroma surgery, trigeminal ganglionectomy, trigeminal rhizotomy, herpes simplex/zoster, diabetes)
Neurotrophic corneas from congenital etiologies (e.g., congenital corneal anesthesia, familial dysautonomia, Seckel's syndrome)
Severe dry eyes (keratoconjunctivitis sicca) from causes such as Sjogren's, chronic graft-versus-host disease, radiation, surgery, meibomian gland deficiency

Scleral Shell Contact Lenses

Scleral shell lenses are medically necessary when ANY of the following are met:

ANY of the following

Treatment of keratoconjunctivitis sicca (dry eye)
Prescribed to support orbital tissue (e.g., sightless and shrunken eye needing support)

Contact Lenses and Eyeglasses for Accidental Injury

An initial pair of contact lenses or eyeglasses is medically necessary when ALL of the following are met:

ALL of the following

Prescribed by a physician
Used to correct a change in vision directly resulting from an accidental bodily injury

Contact Lenses for Masking Irregular Astigmatism Associated with Keratoconus and Other Corneal Disorders

Evaluation and fittings (including corneal topography and scleral lenses) are medically necessary for keratoconus and similar disorders; coverage depends on the member's benefit and plan exclusions.

ALL of the following

Services that are part of evaluation (general exam, advanced corneal topography) and fitting of contact/scleral lenses are medically necessary
If the medical plan excludes contact lenses/vision aids, these are covered under the member’s vision care plan only

Contact Lenses for Myopia Management

Certain lenses for myopia management are considered medically necessary when specific device- and patient-selection criteria are met.

ANY of the following

Acuvue Abiliti Overnight Therapeutic Lenses — for myopia up to 4.00 D and ≤1.5 D astigmatism (orthokeratology overnight wear), when prescribed/managed by qualified eye professional
MiSight 1 Day Soft Contact Lenses — for children 8 to 12 years with refraction -0.75 to -4.00 D (spherical equivalent) and ≤0.75 D astigmatism, for myopia correction and slowing progression

Not Medically Necessary / Features Not Covered

Aetna considers the following not medically necessary unless specifically documented:

ANY of the following

Anti-reflective coating, tints, or oversize lenses (unless documented medically necessary)
Eyeglass cases
Mirror coating (colored, highly-reflective lens treatments)
Polarization
Progressive lenses

Experimental and Investigational

The following are considered experimental and investigational (not covered):

ANY of the following

Blue light filtering contact lenses for improvement of sleep and use of electronic devices
Corneal bandages for all other indications (except those listed as covered)
MiSight 1 Day Soft Contact Lenses for all other indications (except the pediatric myopia management criteria listed)
Orthokeratology lenses for correction of myopia and all other indications (except Acuvue Abiliti overnight lenses as specified)

Relevant CPT / HCPCS / ICD-10 Codes

Prosthetic Contact Lenses and Eyeglasses for Aphakia - CPTCPTCovered

92311	Prescription/fitting contact lens; corneal lens for aphakia, 1 eye
92312	Corneal lens for aphakia, both eyes
92315	Prescription/fitting by independent technician; corneal lens for aphakia, 1 eye
92316	Corneal lens for aphakia, both eyes (tech)
92326	Replacement of contact lens
92352	Fitting of spectacle prosthesis for aphakia
92353	Fitting of spectacle prosthesis for aphakia (additional code listed)
92358	Prosthesis service for aphakia, temporary (disposable or loan, incl. materials)

Prosthetic Contact Lenses and Eyeglasses for Aphakia - CPT Not CoveredCPTNot Covered

92371

Repair and refitting spectacles; spectacle prosthesis for aphakia (not covered for CPB indications)

Prosthetic Contact Lenses and Eyeglasses for Aphakia - HCPCSHCPCSCovered

S0592	Comprehensive contact lens evaluation
V2020	Frames, purchases
V2100-V2499	Eyeglasses (range)
V2500-V2525	Contact lens (range) [except V2526 noted as excluded elsewhere]
V2530-V2599	Contact lens (range)
V2630-V2632	Intraocular lenses
V2782	Lens, index 1.54–1.65 plastic or 1.60–1.79 glass, excludes polycarbonate, per lens
V2783	Lens, index >=1.66 plastic or >=1.80 glass, excludes polycarbonate, per lens
V2784	Lens, polycarbonate or equal, any index, per lens

Prosthetic Contact Lenses and Eyeglasses - HCPCS Not CoveredHCPCSNot Covered

S0504	Single vision prescription lens (safety/athletic/sunglass), per lens
S0506	Bifocal vision prescription lens, per lens
S0508	Trifocal vision prescription lens, per lens
S0510	Non-prescription lens (safety, athletic, or sunglass), per lens
S0514	Color contact lens, per lens
S0516	Safety eyeglass frames
S0518	Sunglasses frames
S0580	Polycarbonate lens (list in addition to basic lens code)
S0581	Nonstandard lens (list in addition to basic lens code)
S0590	Integral lens service, miscellaneous

1–10 of 24

1/3

Aphakia ICD-10 (covered if criteria met)ICD-10Covered

H25.011-H26.9	Cataract (range)
H27.00-H27.03	Aphakia (range)
Q12.0	Congenital cataract
Q12.3	Congenital aphakia
Z96.1	Presence of intraocular lens
Z98.41-Z98.49	Cataract extraction status

Therapeutic Hydrophilic Contact Lenses (CPT)CPTCovered

92071	Fitting of contact lens for treatment of ocular surface disease
92072	Fitting of contact lens for management of keratoconus, initial fitting

Therapeutic Hydrophilic Contact Lenses (HCPCS)HCPCSCovered

S0515	Scleral lens, liquid bandage device, per lens
V2520-V2523	Contact lens, hydrophilic (range)
V2530	Contact lens, scleral, gas impermeable, per lens
V2531	Contact lens, scleral, gas permeable, per lens

Therapeutic Hydrophilic Contact Lenses (ICD-10)ICD-10Covered

B02.30-B02.39	Zoster ocular disease
D89.811	Chronic graft-versus-host disease
G90.1	Familial dysautonomia
H02.881-H02.888	Meibomian gland dysfunction of eyelid
H04.121-H04.129	Dry eye syndrome of lacrimal gland
H16.211-H16.219	Exposure keratoconjunctivitis
H16.221-H16.229	Keratoconjunctivitis sicca, not specified as Sjogren's
H16.231-H16.239	Neurotrophic keratoconjunctivitis
H18.811-H18.819	Anesthesia and hypoesthesia of cornea
L12.1	Cicatricial pemphigoid

1–10 of 20

1/2

Scleral Shell Contact Lenses - CPTCPTCovered

92313	Prescription/fitting; corneoscleral lens
92317	Prescription/fitting by technician; corneoscleral lens

Scleral Shell Contact Lenses - HCPCSHCPCSCovered

V2627

Scleral cover shell

Scleral Shell Contact Lenses - ICD-10ICD-10Covered

H04.121-H04.129	Dry eye syndrome of lacrimal gland
H05.10	Unspecified chronic inflammatory disorders of orbit
H05.30-H05.359	Deformity of orbit
H16.221-H16.229	Keratoconjunctivitis sicca
M35.00-M35.09	Sicca syndrome

Contact Lenses and Eyeglasses for Accidental Injury - CPTCPTCovered

92310	Prescription/fitting; corneal lens, both eyes, except aphakia [initial]
92314	Prescription/fitting by technician; corneal lens, both eyes except aphakia [initial]

Contact Lenses for Masking Irregular Astigmatism - CPT/HCPCSmixedCovered

92025	Computerized corneal topography, with interpretation and report
92071	Fitting of contact lens for treatment of ocular surface disease
92072	Fitting of contact lens for management of keratoconus, initial fitting
S0592	Comprehensive contact lens evaluation
V2500-V2513	Contact lens (range)

Contacts for Myopia Management - CodesmixedCovered

92310	Prescription/fitting; corneal lens, both eyes, except aphakia [initial]
92314	Prescription/fitting by technician; corneal lens, both eyes except aphakia [initial]
S0592	Comprehensive contact lens evaluation
V2525	Contact lens, hydrophilis, dual focus, per lens [MiSight 1 Day]

Accidental Injury ICD-10 (covered if criteria met)ICD-10Covered

H44.601-H44.799	Retained (old) intraocular foreign body
S00.10XA-S00.12XS	Contusion of eyelid and periocular area
S00.201A-S00.279S	Superficial injuries of eyelid and periocular area
S01.101A-S01.159S	Open wound of eyelid and periocular area
T15.00XA-T15.92XS	Foreign body on external eye
Z87.821	Personal history of retained foreign body fully removed

Keratoconus / Corneal Ectasia ICD-10ICD-10Covered

H17.00-H17.9	Corneal scars and opacities
H18.40-H18.9	Corneal degeneration
H18.601-H18.629	Keratoconus
H18.711-H18.719	Corneal ectasia [post-LASIK]
Q13.4	Other congenital corneal malformations
Q15.0	Congenital glaucoma [keratoglobus]

Myopia ICD-10 (for myopia management coverage)ICD-10Covered

H52.10-H52.13

Myopia (range)

Billing, Prior Authorization, and Documentation Actions

Documentation Required

Verify member benefits and exclusions

Confirm whether the member's medical plan excludes coverage of contact lenses or eyeglasses and, if so, check the member's vision care plan for any additional coverage before billing medical benefits. If the medical plan excludes contact lenses/vision aids, these items would be covered only under the vision care plan where applicable.

Documentation Required

Medical necessity documentation for prosthetic features

When requesting coverage for features that are not generally considered medically necessary (for example, anti-reflective coating, tints, oversize lenses), document the specific medical justification for those features on the claim.

Affected codes include V2744, V2745, V2750, V2780, V2781.

Numeric & Device Eligibility Thresholds

Myopia-management lens thresholds

MiSight 1 Day eligibility - age8 to 12 years

MiSight 1 Day refractive rangeSpherical equivalent -0.75 to -4.00 D; astigmatism ≤ 0.75 D

Acuvue Abiliti Overnight refractive rangeMyopia up to -4.00 D; astigmatism ≤ 1.50 D

MiSight trial spherical equivalent refraction (enrollment range)-0.75 to -4.00 D

MiSight trial astigmatism (enrollment limit)< 1.00 D

Recommended daily wear time for MiSight lensesMinimum 10 hours per day for at least 6 days per week

Clinical and Administrative Background

Therapeutic soft hydrophilic contact lenses (bandage lenses) and fluid-ventilated scleral lenses are used as moist corneal bandages to protect the cornea, manage severe ocular surface disease, and rehabilitate or mask irregular corneal surfaces and irregular astigmatism. Hydrophilic bandage lenses cover the cornea and may be used for conditions such as bullous keratopathy and other epithelial disorders; prophylactic topical antibiotics and most therapeutic eye drops can be used with these lenses. The Boston scleral lens is a fluid-ventilated gas-permeable design that creates an aqueous reservoir over the cornea and can be used when corneal contact is not tolerated. Scleral shell lenses (large-diameter hard scleral prosthetic lenses) fit over the exposed surface of the eye and can also support orbital tissue when an eye is sightless and shrunken, functioning in some cases as an artificial eye or to prolong tear film contact time for severe dry eye syndromes.

Aphakic contact lenses and spectacles are considered prosthetic devices to replace the crystalline lens after cataract removal or in congenital aphakia. Clinical trial evidence in infants (the Infant Aphakia Treatment Study) showed similar median visual acuity at follow-up for eyes corrected with contact lenses versus primary intraocular lens (IOL) implantation, but higher rates of adverse events and additional intraocular surgeries in the primary IOL group; investigators recommended leaving some infants aphakic and correcting with contact lenses when appropriate. Secondary IOL implantation after initial aphakic management has been associated with more predictable refractive outcomes in later childhood but a wide range of refractive errors remains possible.

For myopia management, Aetna notes two device classes with FDA review and trial data. Acuvue Abiliti Overnight are orthokeratology lenses FDA-approved for overnight wear to temporarily reduce myopia up to -4.00 D with up to 1.50 D astigmatism; they reshape the cornea during sleep and require ongoing nightly wear to maintain effect. MiSight 1 Day daily disposable soft contact lenses are FDA-approved for children aged 8 to 12 years with spherical equivalent refraction from -0.75 to -4.00 D and ≤ 0.75 D astigmatism for correction of myopia and slowing myopia progression. The pivotal randomized trial of MiSight (Chamberlain et al.) enrolled 144 children (75.5% completed) and demonstrated significantly less progression in spherical equivalent refraction and less axial elongation in the MiSight group versus controls over 3 years, with no serious ocular adverse events reported in the trial.

Defined Terms

Definitions

AphakiaAbsence of the lens of the eye, surgically removed (e.g., cataract extraction) or congenitally absent; contact lenses/eyeglasses may be considered prosthetic in these members.

Scleral lensA gas-permeable lens that rests on the sclera and creates a fluid reservoir over the cornea, used as a bandage or to mask irregular astigmatism.

Therapeutic hydrophilic contact lensSoft (hydrophilic) contact lens used as a corneal bandage to protect the ocular surface in severe disease.

MiSight 1 DayA daily-disposable soft contact lens indicated for myopia management in children; studied in randomized controlled trials showing reduced myopic progression.

PVR-PROSE (PROSE) scleral lensLarge-diameter gas-permeable scleral prosthetic lens designed to vault the cornea and rest on the sclera, creating a fluid reservoir to rehabilitate irregular corneas and severe ocular surface disease.

ReCSS study

Contact Lenses and Eyeglasses

Medical Necessity Criteria

Relevant CPT / HCPCS / ICD-10 Codes

Billing, Prior Authorization, and Documentation Actions

Numeric & Device Eligibility Thresholds

Clinical and Administrative Background

Defined Terms

Also Review