CurrentBaylor Scott & White Health PlanPolicy N/A

Keratoconus and Medical Contact Lenses

This policy defines medical necessity criteria for evaluation and selected treatments for keratoconus and other corneal disorders, and describes when contact lenses and corneal collagen cross-linking are considered medical benefits under Baylor Scott & White Health Plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyKeratoconus and Medical Contact Lenses

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateApr 10, 2026

Key ActionVerify the member's Evidence of Coverage or Summary Plan Description to confirm whether contact lens coverage is included before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not requiredprior authorization requirement

14-65age range

Photrexaproduct referenced

0402Tprocedure code

Coverage criteria — contact lenses, corneal bandage, and cross-linking

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Contact lenses as medical benefit (selected indications)

Contact lenses are considered medically necessary for select indications when the member's plan allows contact lens coverage.

Selected indications for medical contact lens coverage: Coverage allowed when contact lens coverage is included in the member's plan and the indication is one of the listed medical conditions

Conditions listed include: external lenses and intraocular lenses after cataract surgery (prosthetic replacement of the lens; limited to standard eyewear), therapeutic hydrophilic 'corneal bandage' for ocular surface disease, and evaluation of keratoconus or other corneal disorders with astigmatism; contact lenses for correction of astigmatism related to corneal disorders are not covered unless the member's plan includes contact lens benefits.

Corneal bandage (therapeutic hydrophilic contact lenses)

Therapeutic hydrophilic contact lenses are medically necessary for specific ocular surface diseases.

Indications: Therapeutic hydrophilic contact lenses (corneal bandage) are considered medically necessary for treatment of: chemical, thermal or other corneal injuries; Stevens-Johnson Syndrome; neurotrophic corneas; corneal disorders associated with autoimmune diseases (e.g., rheumatoid arthritis, epidermal disorders such as epidermolysis bullosa, ectodermal dysplasia); keratoconjunctivitis sicca as in Sjogren's syndrome; epidermal ocular disorders; corneal exposure (anatomic or paralytic); bullous keratopathy; and corneal abrasion.

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

Epithelium-off collagen cross-linking (Photrexa / riboflavin + UVA)

Epithelium-off photochemical collagen cross-linking using riboflavin (Photrexa) and UVA is considered medically necessary when ALL criteria are met:

Cross-linking criteria: Member is between the ages of 14 and 65 years and is not pregnant; AND member has progressive keratoconus; AND the central cornea is clear without scarring or disease.Age 14-65 years

Procedure referenced as Photrexa; CPT code 0402T listed in coding section.

Evaluation of keratoconus and corneal disorders with astigmatism

Evaluation is considered medically necessary.

Evaluation of members with keratoconus and other corneal disorders with astigmatism is medically necessary.

Correction with contact lenses will not be covered as a medical benefit for astigmatism associated with these disorders unless the member's plan includes contact lens coverage.

Most Baylor Scott & White Health Plan (BSWHP) medical plans exclude coverage of routine eyeglasses and corrective lenses unless a separate "vision" rider applies. If a member's plan excludes contact lens coverage, then contact lenses are not covered even when prescribed for keratoconus or other corneal conditions; a few plans exclude contact lenses under all conditions. Providers should review the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) to determine whether contact lens benefits are included before submitting requests for coverage.

Therapeutic hydrophilic contact lenses (commonly referred to as "corneal bandage" lenses) are specified in this policy as medically necessary only for the listed ocular surface diseases, including chemical or thermal corneal injuries; Stevens‑Johnson syndrome; neurotrophic corneas; corneal disorders associated with autoimmune or epidermal disorders; keratoconjunctivitis sicca (e.g., Sjogren's syndrome); corneal exposure; bullous keratopathy; and corneal abrasion. Use of corneal bandage lenses for any other indication is considered experimental and investigational and is not covered.

Evaluation of keratoconus and other corneal disorders with astigmatism is medically necessary. However, contact lenses for correction of astigmatism associated with these corneal disorders will NOT be covered as a medical benefit unless the member's plan includes contact lens coverage. Verify plan benefits prior to authorizing or procuring contact lenses for astigmatic correction related to corneal disease.

Coding — CPT, HCPCS, and ICD-10 notes

Covered CPT Codes (examples)CPT

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)

ICD-10 / HCPCS note groups (document uses mixed labeling)mixed

92072

Fitting of Contact Lens for Management of Keratoconus

HCPCS CodesHCPCS

V2520	Contact lens specific for aphakia
V2523	Contact lens specific for aphakia

ICD-10 Not CoveredICD-10Not Covered

H18.6xx

Keratoconus (listed as ICD-10 Not Covered in the document)

Age

Age rangeMember between 14 and 65 years

Pregnancy statusMember must not be pregnant

Procedure eligibility noteApplies to epithelium-off photochemical collagen cross-linking (Photrexa + UVA)

Provider actions and billing considerations

Documentation Required

Verify member plan benefits

Prior authorization not required for services covered under this policy. Review the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) to confirm whether contact lenses or eyeglasses are excluded under the members medical plan; document medical necessity in the medical record and on the claim when submitting for coverage.

If the member's plan excludes contact lenses/eyewear under the medical benefit, claims will be denied regardless of medical necessity.
If contact lens coverage is not excluded for all conditions, coverage may be considered medically necessary for specific indications (e.g., post-cataract intraocular lenses, therapeutic hydrophilic "bandage" lenses for ocular surface disease, select indications for keratoconus) — document applicable diagnosis and clinical justification.
For Medicare members, follow applicable NCDs/LCDs when present; if none, apply policy criteria.
For Medicaid members (Texas), confirm TMPPM guidance; if none, apply policy criteria.

Denial Risk

Plan exclusion may trigger denial

Some BSWHP medical plans explicitly exclude contact lens and eyeglass coverage under all conditions. If the member's plan contains such an exclusion, any request for coverage must be denied even when medical necessity criteria are met.

Affected claims: contact lenses, frames, and standard eyewear billed to medical benefit when exclusion applies.
Action: Confirm exclusion in the EOC/SPD before rendering or billing services and notify the member/provider of non-coverage.
Documentation: Retain EOC/SPD reference and member notification in the medical record to support denial decisions.

Background and scope

Keratoconus is a progressive, non‑inflammatory thinning of the cornea that produces a cone‑shaped protrusion and can lead to visual impairment. Management is directed at preserving vision: initial treatment emphasizes optical correction with spectacles or contact lenses, while surgical options — including corneal transplantation (keratoplasty) — may be considered when visual acuity cannot be adequately restored with lenses. Emerging interventions such as epithelium‑off collagen cross‑linking (using riboflavin/Photrexa and UVA) aim to halt progression in appropriately selected patients.

Key definitions

Keratoconus

DefinitionKeratoconus is a non-inflammatory disorder of the cornea characterized by progressive thinning and cone-shaped protrusion leading to visual impairment.

EtiologyOf unknown etiology

Clinical consequenceLeads to visual impairment; treatment focuses on vision correction with spectacles or contact lenses; keratoplasty may be considered when vision cannot be corrected with contact lenses.

Collagen cross-linking (epithelium-off)

Procedure nameEpithelium-off photochemical collagen cross-linking (using riboflavin — Photrexa — and ultraviolet A)

Key componentsRemoval of corneal epithelium, riboflavin (Photrexa) application, and UVA irradiation to stiffen corneal collagen

IndicationFor progressive keratoconus or keratectasia when central cornea is clear and other criteria are met