CurrentBaylor Scott & White Health PlanPolicy 229

Keratoconus and Medical Contact Lenses

Customize your policy alerts

Sign up for Baylor Scott & White Health Plan Policy 229 alerts

Get alerted when Policy 229 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity and coverage criteria for keratoconus, corneal disorders, therapeutic contact lenses (including corneal bandages), and collagen cross-linking; applies to Baylor Scott & White Health Plan lines of business and members in applicable jurisdictions.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyKeratoconus and Medical Contact Lenses

Policy CodePolicy 229

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewApr 23, 2026

Next Review DateApr 23, 2027

Key ActionReview member's Evidence of Coverage/Plan SPD to confirm contact lens benefit before relying on medical necessity in this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not required

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentBaylor Scott & White Health PlanPolicy 229

Keratoconus and Medical Contact Lenses

Customize your policy alerts

Sign up for Baylor Scott & White Health Plan Policy 229 alerts

Get alerted when Policy 229 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyKeratoconus and Medical Contact Lenses

Policy CodePolicy 229

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewApr 23, 2026

Next Review DateApr 23, 2027

Key ActionReview member's Evidence of Coverage/Plan SPD to confirm contact lens benefit before relying on medical necessity in this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not required

Coverage and Medical Necessity Criteria

Medically Necessary Criteria

Covered when ALL of the following are met (as applicable to the indicated service):

Contact lenses as prosthetics after cataract surgery: External lenses and intraocular lenses are medically necessary after cataract surgery to replace the lens; coverage is limited to standard eyewear (special coatings/tints/deluxe frames not considered medically necessary).

Applies when plan does not exclude eyewear; see member Evidence of Coverage/Plan SPD.

Therapeutic hydrophilic contact lenses (corneal bandage): Medically necessary for treatment of ocular surface disease including Stevens-Johnson syndrome; chemical, thermal or other corneal injuries; neurotrophic corneas; keratoconjunctivitis sicca (e.g., Sjogren's syndrome); corneal disorders associated with autoimmune diseases; epidermal ocular disorders (e.g., atopy, ectodermal dysplasia, epidermolysis bullosa); corneal exposure (anatomic or paralytic); bullous keratopathy; and corneal abrasion.

Corneal bandage is considered experimental/investigational for all other indications.

Evaluation of keratoconus and corneal disorders: Evaluation of members with keratoconus and other corneal disorders with astigmatism is medically necessary; however contact lenses will not be covered for correction of astigmatism unless the member's plan includes contact lens coverage.

Epithelium-off collagen cross-linking (Photrexa + UVA): Considered medically necessary for keratoconus and keratectasia when all of the following are met: member has progressive keratoconus; member is between 14 and 65 years of age and is not pregnant; and the central cornea is clear without scarring or disease.age 14-65; not pregnant; clear central cornea

Procedure code 0402T referenced.

Contact lenses used solely to correct astigmatism associated with keratoconus or other corneal disorders are not covered as a medical benefit unless the member's plan includes contact lens coverage. Evaluation and management of keratoconus and other corneal disorders with astigmatism is medically necessary, but coverage of corrective contact lenses for astigmatism is contingent on the member's Evidence of Coverage/Summary Plan Description and any applicable vision rider or plan exclusion. Providers should confirm member benefits before ordering or billing contact lenses as a medical benefit.

Therapeutic hydrophilic contact lenses (corneal bandage) are listed as medically necessary for specific ocular surface diseases (for example, Stevens-Johnson syndrome, chemical or thermal corneal injuries, neurotrophic corneas, Sjogren-related keratoconjunctivitis sicca, corneal disorders associated with autoimmune or epidermal ocular disorders, corneal exposure, bullous keratopathy, and corneal abrasion). Corneal bandage lenses are considered experimental and investigational for all other indications not listed in the policy.

Billing and Codes

Covered CPT CodesCPT

92071	Fitting of Contact Lens for Treatment of Ocular Surface Disease
92311	Fitting of contact lens, corneal lens for aphakia
92312	Fitting of contact lens, corneal lens for aphakia
92315	Fitting of contact lens, corneal lens for aphakia
92316	Fitting of contact lens, corneal lens for aphakia
0402T	Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

CPT/ICD-10 mapping and not covered notemixed

92072

Fitting of Contact Lens for Management of Keratoconus

Not Covered Mapping (ICD-10)ICD-10

H18.6xx

Keratoconus (listed as Not Covered mapping for 92072)

HCPCSHCPCS

V2520	contact lens specific for aphakia
V2523	contact lens specific for aphakia

Example ICD-10 codesICD-10

Q12.3	Congenital aphakia
H18.6xx	Keratoconus (listed as Not Covered mapping for 92072)

inv-08: Age range for collagen cross-linking — 14 - 65 years.

Age range14 - 65 years

Additional age-related requirementMember must not be pregnant

Applies toEpithelium-off photochemical collagen cross-linking (Photrexa + UVA) for keratoconus/keratectasia

Provider Requirements and Authorization

Prior Authorization

Prior authorization not required

Prior authorization is not required for services covered by this policy.

Note

Documentation Required

Verify member plan benefits (EOC/SPD)

Review the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) to confirm whether contact lenses are a covered benefit; medical necessity under this policy does not guarantee that the plan will provide coverage and the plan document supersedes the policy.

Clinical Background

Keratoconus is a non‑inflammatory, progressive thinning of the cornea that leads to a characteristic cone‑shaped protrusion and visual impairment. Management emphasizes visual rehabilitation with spectacles or contact lenses, and when vision cannot be adequately corrected with contact lenses, keratoplasty may be considered. For progressive disease, epithelium‑off photochemical collagen cross‑linking (Photrexa + UVA) is a treatment option when specific criteria are met (progression of keratoconus, age 14–65 years and not pregnant, and a clear central cornea without scarring or disease).

Key Terms and Definitions

inv-14: Definition — keratoconus described as a non-inflammatory disorder of the cornea characterized by progressive thinning and cone-shaped protrusion causing visual impairment.

DefinitionKeratoconus: a non-inflammatory disorder of the cornea characterized by progressive thinning and cone-shaped protrusion causing visual impairment

EtiologyUnknown

Clinical consequenceProgressive corneal deformation leading to visual impairment; may require spectacles, contact lenses, or keratoplasty