ModifiedMass General Brigham Health PlanPolicy 055

Therapeutic Lens (contact, scleral, PROSE) coverage

Defines medical necessity, prior authorization, and coverage criteria for therapeutic lenses (conventional contact lenses, scleral lenses, and PROSE) for Mass General Brigham Health Plan members across Medicare Advantage, Mass General Brigham ACO, One Care/SCO, and Commercial plans.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTherapeutic Lens (contact, scleral, PROSE) coverage

Policy CodePolicy 055

Change TypeMaterial exclusion added (Nov 2023) and several formatting/clarity updates (2025–2026)

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for therapeutic lenses.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy and removed reference to retired custom InterQual® subset; clarified criteria hierarchy in One Care and SCO section.

Updated prior authorization table and added variation for One Care and SCO members; fixed code disclaimer and updated LCD and LCA references.

Summary of Evidence section added.

Exclusion added for lens for cosmetic purposes.

YesMedicare Advantage PA

YesMass General Brigham ACO PA

YesCommercial PA

1Policy number

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2008-2023Evidence timeframe

Coverage and Medical Necessity Criteria

Conventional Contact Lens (soft or RGP) - Initial

Covered when ONE of the following is met:

Conventional contact lens indications: Member has keratoconus or other corneal ectasia or irregular astigmatism that cannot be corrected with spectacles; OR anisometropia of more than 3.00 diopters (D); OR hyperopia of more than 7.00 D; OR myopia of more than 7.00 D; OR post-operative cataract extraction.n=1

Restrictions may apply; refer to member handbook.

Scleral Lens or PROSE - Initial

Covered when ALL of the following are met in EITHER item A or item B:

Option A: Member has impaired vision requiring medically necessary vision correction AND conventional glasses or conventional contact lenses are insufficient AND the scleral lens must significantly improve vision.all

Option A addresses visual rehabilitation where scleral lens provides significant vision improvement.

Option B: Member requires a moist corneal bandage (scleral lens) for medical treatment of severe ocular surface disease AND conventional treatments are contraindicated or have failed to treat one of the listed conditions.all

Listed conditions (not all inclusive): 1) Severe Dry Eye Disease/Dry Eye Syndrome; 2) Limbal Stem Cell Deficiency; 3) Neurotrophic Keratopathy; 4) Corneal Degenerations and Dystrophies; 5) Extensive corneal scarring after trauma, infection, or surgery that leads to blindness and is cosmetically disfiguring; 6) High or irregular astigmatism after trauma, infection, or surgery.

The policy excludes coverage of scleral lenses when they are prescribed solely for routine vision correction or for purely cosmetic reasons. Specifically, scleral lens for ordinary refractive error and lenses used exclusively for cosmetic purposes are not covered under this policy.

This section contains reference citations relevant to scleral lens and PROSE use, including peer-reviewed studies and external guidance, and does not itself enumerate additional exclusion language. These references are provided to support clinical context and evidence reviews but do not alter the policy exclusions stated elsewhere.

Use of a scleral lens for ordinary refractive error or when the device is fitted solely for cosmetic purposes is explicitly excluded and considered not medically necessary under this policy.

The listed reference materials include clinical studies and external guidance but do not themselves contain explicit 'not medically necessary' statements. Any formal exclusion or NMN determinations are stated in the policy exclusions section, not in these reference citations.

Authorized Billing and Procedure Codes

Authorized Codemixed

92314	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes
92340	Fitting of spectacles, except for aphakia; monofocal
92341	Fitting of spectacles, except for aphakia; bifocal
92342	Fitting of spectacles, except for aphakia; multifocal, other than bifocal
92352	Fitting of spectacle prosthesis for aphakia; monofocal
92353	Fitting of spectacle prosthesis for aphakia; multifocal
92354	Fitting of spectacle mounted low vision aid; single element system
92355	Fitting of spectacle mounted low vision aid; telescopic or other compound lens system
92358	Prosthesis service for aphakia, temporary (disposable or loan, including materials)
92370	Repair and refitting spectacles; except for aphakia

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Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization is required for therapeutic lenses. The treating specialist must request prior authorization for therapeutic lenses. For Medicare Advantage members, Mass General Brigham Health Plan follows CMS guidance (NCDs, LCDs, LCAs, and Medicare manuals) first; when CMS guidance is absent or insufficient, this policy's criteria are applied.

Treating specialist must request prior authorization for therapeutic lenses.
Medicare Advantage: follow CMS NCDs/LCDs/LCAs first; use this policy when CMS guidance is insufficient.

Note

External LCD / LCA References Cited

Mass General Brigham Health Plan cites Noridian Local Coverage Determination L33737 (Eye Prostheses) and Noridian Local Coverage Article A52462 as external references that inform coverage decisions for scleral lenses, PROSE, and related eye prostheses. These Noridian documents may influence whether a request meets medical necessity for Medicare-related members.

Noridian LCD: Eye Prostheses (L33737).

Background and Clinical Context

Scleral lenses and PROSE are specialized therapeutic devices used primarily for complex corneal and ocular surface disease and for visual rehabilitation when conventional spectacles or standard contact lenses are inadequate. The literature cited in this policy documents benefits such as improved visual acuity and quality of life in conditions like keratoconus and severe ocular surface disease, and supports the role of scleral devices in reducing the need for corneal transplantation and in treating severe ocular surface disorders. Clinical use requires precise fitting and monitoring because scleral lens wear can have physiological effects (for example, changes in intraocular pressure or corneal thickness) that should be managed by the treating specialist.

Key Terms and Definitions

Anisometropia — definition entry

TermAnisometropia

DefinitionA condition in which the lenses of the two eyes have different focal lengths and are in different states of myopia (nearsightedness) and hyperopia (farsightedness).

Clinical relevanceCan cause unequal refractive errors between eyes that may require specialized optical correction such as contact lenses or therapeutic lenses when spectacles are insufficient.

Aphakia — definition entry

TermAphakia

DefinitionThe absence of the lens of the eye, due to surgical removal, a wound, ulcer, or as a condition present at birth (congenital anomaly).

Policy Revisions and Notes

2026-03ad_hoc_reviewLatest

Reformatted policy; removed reference to retired custom InterQual® subset; clarified criteria hierarchy for One Care and SCO.

2026-01annual_review

Updated prior authorization table and added variation for One Care and SCO members; fixed code disclaimer and updated LCD and LCA references.

2025-03ad_hoc_review

Added 'Summary of Evidence' section to the policy.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTherapeutic Lens (contact, scleral, PROSE) coverage

Policy CodePolicy 055

Change TypeMaterial exclusion added (Nov 2023) and several formatting/clarity updates (2025–2026)

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for therapeutic lenses.

SourceLink

On This Page

Noridian LCA: Eye Prostheses - Policy Article (A52462).

Note

Reference List (Informational)

Reference list only — the References section provides source literature and Noridian citations for clinical context but does not by itself constitute provider documentation or submission requirements. Providers must include clinical documentation described elsewhere in the policy when requesting authorization.

References include peer-reviewed studies and Noridian LCD/LCA citations.
References are for review and clinical context only — they do not replace required provider documentation for authorizations.

Documentation Required

Conservative Treatment Requirement

Conservative treatments must be contraindicated or have failed before coverage is considered when a scleral lens or PROSE is requested as a moist corneal bandage for severe ocular surface disease. Providers should document prior conventional treatments and reasons for failure or contraindication in the authorization request.

For moist corneal bandage (scleral lens/PROSE): document that conventional treatments were tried and failed or are contraindicated.
Conditions include severe dry eye disease, limbal stem cell deficiency, neurotrophic keratopathy, corneal degenerations/dystrophies, extensive corneal scarring, or high/irregular astigmatism after trauma/infection/surgery.

Denial Risk

Exclusions and Denial Risk

Exclusions and denial risk: requests for scleral lenses for ordinary refractive error or solely for cosmetic purposes are excluded and may be denied. Ensure clinical justification aligns with policy criteria and cited LCD/LCA guidance to reduce denial risk.

Scleral lens for ordinary refractive error — excluded.
Lenses for exclusively cosmetic purposes — excluded.
Align documentation with Noridian LCD/LCA and this policy to support medical necessity.

Clinical relevanceOften requires specialized lenses (e.g., contact or spectacle prosthesis) for visual rehabilitation and may be an indication for therapeutic lens fitting.

Keratoconus — definition entry

TermKeratoconus

DefinitionA degenerative vision disorder in which the normally round cornea becomes thin and irregular (cone) shaped, preventing light from being focused correctly on the retina and causing distortion of vision.

Clinical relevanceOften managed with specialized contact lenses (e.g., rigid gas-permeable, scleral lenses) when spectacles are inadequate for visual correction.

LASIK — definition entry

TermLASIK

DefinitionEye surgery in which the surface of the cornea is reshaped using a laser, performed to correct certain refractive disorders such as myopia.

Clinical relevanceA history of LASIK may affect residual refractive error and candidacy for certain therapeutic lenses; post‑surgical irregularities can require specialty fittings.

PROSE — definition entry

TermPROSE

DefinitionProsthetic Replacement of the Ocular Surface Ecosystem (PROSE), a medical treatment for complex corneal disease developed by the Boston Foundation for Sight.

Clinical relevanceA scleral device therapy used for severe ocular surface disease and visual rehabilitation when conventional treatments or lenses are insufficient.

Scleral Lens — definition entry

TermScleral Lens

DefinitionA contact lens generally worn directly on the sclera, which fits underneath the top and bottom eyelids.

Clinical relevanceUsed for visual rehabilitation in conditions like keratoconus and as a moist corneal bandage for ocular surface disease when conventional lenses fail.

Therapeutic Lens — definition entry

TermTherapeutic Lens

DefinitionLenses that provide visual rehabilitation for diseased or altered eyes.

Clinical relevanceIncludes conventional contact lenses, scleral lenses, and PROSE devices used to treat or rehabilitate vision in medically indicated situations.

PROSE / Boston Ocular Surface Prosthesis (scleral device) — named device entry

DevicePROSE / Boston Ocular Surface Prosthesis (scleral device)

DescriptionNamed scleral device therapies referenced in multiple studies for visual rehabilitation and ocular surface disease management (PROSE developed by Boston Foundation for Sight).

EvidenceCited studies in the references list report quality-of-life and clinical outcomes after scleral lens/PROSE fitting for keratoconus and ocular surface disease.

2023-11annual_review

Added exclusion for lenses used for exclusively cosmetic purposes and added Medicare Advantage language and references.