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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometrySelect Health therapeutic contact lenses Coverage …
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    Currentselect_healthPolicy CCP.1077

    Therapeutic Contact Lenses

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    Defines medical necessity and coverage criteria for therapeutic contact lenses (including hydrophilic, gas-permeable scleral, Boston scleral, scleral shell) and amniotic membrane transplantation for ocular surface disease and acute burns; applies to Select Health of South Carolina members and their providers.

    Policy Summary
    Payerselect_health
    PolicyTherapeutic Contact Lenses
    Policy CodePolicy CCP.1077
    Change TypeNo material change
    Effective DateFeb 1, 2024
    Last ReviewFeb 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain prior authorization when fitting or performing procedures for therapeutic contact lenses or amniotic membrane placement if required by the member's plan.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    MultipleLens modalities described
    Case-by-caseAmniotic membrane coverage

    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.

    Other usesNot medically necessary
    CPT/HCPCSCodes provided

    Coverage Criteria

    Therapeutic contact lenses (initial coverage criteria)

    Covered when ALL of the following are met

    Therapeutic lens type: Use of one of the following lens types: contact lenses placed after cataract surgery (considered prostheses unless the member's benefit plan specifies otherwise); hydrophilic soft contact lenses or gas-permeable fluid-ventilated scleral lenses for management of severe corneal disease; Boston scleral lens when used as a moist corneal bandage if lubricants/drops are not appropriate; scleral cover shell for treatment of severe keratoconjunctivitis sicca or when orbital support is required due to loss of corneal strength.
    Functional impairment / treatment goals: At least one of the following: unable to achieve vision of 20/40 or better despite best correction with eyeglasses or typical contact lenses; use of the lens will delay or prevent the need for corneal transplantation; use of the lens will improve performance of activities of daily living.

    Amniotic membrane transplantation

    Amniotic membrane transplantation covered when ALL of the following are met

    Indication: Condition requiring acute treatment such as chemical or thermal injuries or limbal stem cell failure.

    Case-by-case basis; used to reduce pain and accelerate healing in severe burns and for limbal stem cell failure.

    Contact lenses provided solely for routine vision correction are governed by the member's benefit plan and are not covered under this therapeutic contact lens policy. Coverage determinations for routine refractive correction should be made in accordance with the member's specific vision or medical benefits.

    Any request for therapeutic contact lenses that does not meet the specific medical necessity criteria in this policy is considered not medically necessary. This includes, but is not limited to, use for routine refractive correction and use for treatment of visual perceptual dysfunction (e.g., dyslexia), which is not clinically proven.

    Coding

    Covered CPT Codes: Contact Lens ServicesCPTCovered
    92071Fitting of contact lens for treatment of ocular surface disease
    92072Fitting of contact lens for management of keratoconus, initial fitting
    Covered CPT Codes: Prescription/fitting and modificationCPTCovered
    92310Prescription of optical and physical characteristics of, and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia
    92311Prescription of optical and physical characteristics of, and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye
    92312Prescription of optical and physical characteristics of, and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes
    92313Prescription of optical and physical characteristics of, and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens
    92325Modification of contact lens (separate procedure), with medical supervision of adaptation
    92326Replacement of contact lens
    Covered CPT Codes: Amniotic membrane placementCPTCovered
    65778Placement of amniotic membrane on the ocular surface; without sutures
    65779Placement of amniotic membrane on the ocular surface; single layer, sutured
    65780Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
    HCPCS Level II Codes: Contact Lens Supplies and DevicesHCPCSCovered
    V2500Contact lens, PMMA, spherical, per lens
    V2501Contact lens, PMMA, toric or prism ballast, per lens
    V2502Contact lens, PMMA, bifocal, per lens
    V2510Contact lens, gas permeable, spherical, per lens
    V2511Contact lens, gas permeable, toric, prism ballast, per lens
    V2512Contact lens, gas permeable, bifocal, per lens
    V2513Contact lens, gas permeable, extended wear, per lens
    V2520Contact lens, hydrophilic, spherical, per lens
    V2521Contact lens, hydrophilic, toric, or prism ballast, per lens
    V2522Contact lens, hydrophilic, bifocal, per lens
    1–10 of 17
    1/2

    Provider Actions & Billing

    Prior Authorization

    Prior authorization may be required for fitting/procedure codes

    Fitting and procedure codes related to therapeutic contact lenses and amniotic membrane placement may require prior authorization per the member's plan; obtain authorization when the service requires it under the member's benefit plan.

    • Common fitting codes: 92071, 92072
    • Prescription/fitting and modification codes: 92310–92313, 92325–92326
    • Amniotic membrane procedure codes: 65778–65780
    Step Therapy

    Step therapy not applicable

    No step therapy protocols apply to this policy; there are no specified step requirements for therapeutic contact lenses or amniotic membrane transplantation.

    Background

    Therapeutic contact lenses are medical devices used to manage ocular surface and severe corneal disease beyond simple refractive correction. Their clinical roles include providing corneal protection and lubrication, reducing pain, creating a fluid reservoir over the cornea to promote healing, sealing or supporting areas of corneal thinning or perforation, and serving as a modality to delay or prevent corneal transplantation when appropriate.

    Specific lens modalities addressed by this policy include hydrophilic (soft) contact lenses, gas-permeable scleral lenses (including Boston scleral lenses that create a bubble-free, oxygenated fluid reservoir), and scleral cover shell lenses that retain artificial tears and provide structural support in eyes with severe keratoconjunctivitis sicca or loss of corneal strength. Additionally, amniotic membrane transplantation is recognized as a surgical option for acute chemical or thermal burns and for limbal stem cell failure to reduce pain and accelerate healing.

    Definitions

    Boston scleral lens — definition
    DefinitionBoston scleral lens: a specially designed fluid-ventilated, gas-permeable scleral contact lens that provides a bubble-free reservoir of oxygenated aqueous fluid over the corneal surface at neutral hydrostatic pressure, suitable for severe corneal disease.
    Primary useUsed as a moist corneal bandage when lubricants or drops are not appropriate, protecting the cornea and supporting healing.
    Design featureFluid-ventilated design creates a reservoir of oxygenated fluid that covers the entire cornea, reducing drying and improving comfort.
    Scleral shell — definition
    DefinitionScleral shell: a contact lens that covers the entire exposed surface of the eye and can retain artificial tears to protect against drying and treat severe keratoconjunctivitis sicca.
    Clinical role
    Policy Summary
    Payerselect_health
    PolicyTherapeutic Contact Lenses
    Policy CodePolicy CCP.1077
    Change TypeNo material change
    Effective DateFeb 1, 2024
    Last ReviewFeb 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain prior authorization when fitting or performing procedures for therapeutic contact lenses or amniotic membrane placement if required by the member's plan.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & BillingBackgroundDefinitions
    Documentation Required

    Document indication, prior treatments, functional impairment, and submit appropriate codes

    Document the clinical indication, prior treatments, and the functional impairment that the lens or procedure is intended to address, and submit the appropriate fitting or procedure codes to support medical necessity.

    • Include relevant fitting/procedure codes (e.g., 92071, 92072, 92310–92313, 92325–92326, 65778–65780)
    • Include HCPCS codes for devices/supplies when applicable (e.g., V25xx, V26xx, S05xx)
    Denial Risk

    Non-covered indications and potential denials

    Requests for therapeutic contact lenses for indications other than those listed in the policy — including routine vision correction or treatment of visual perceptual dysfunction (e.g., dyslexia) — are considered not medically necessary and may be denied.

    • Routine vision correction is governed by the member's benefit plan and not covered under this policy
    • Treatment of visual perceptual dysfunction (such as dyslexia) with contact lenses is not clinically proven and not medically necessary
    Provides structural support and protection when severe corneal disease has rendered the eye nonfunctional and may help prevent enucleation.
    MechanismHolds instilled artificial tears against the ocular surface and shields the eye from environmental exposure and further injury.
    Amniotic membrane transplantation — definition
    DefinitionAmniotic membrane transplantation: surgical placement of amniotic membrane on the ocular surface to reduce pain and accelerate healing in cases of severe thermal or chemical corneal burns and for limbal stem cell failure.
    IndicationsUsed for acute conditions requiring treatment such as chemical or thermal injuries and limbal stem cell failure; coverage considered on a case-by-case basis.
    Clinical effectAims to reduce pain and promote epithelial healing of the ocular surface following severe injury.