Medically Necessary Contact Lens Clinical Criteria

Document Keratoconus Corneal Testing

For keratoconus, document corneal testing supporting the diagnosis. Topography, OCT, or corneal mapping is preferred; keratometry should also be documented.

• Topography, OCT, or corneal mapping (preferred)
• Keratometry

Document High Ametropia Findings

For high ametropia, submit the required eyeglass prescription and document visual acuity findings for each eye, including the improvement achieved with contact lenses.

• Eyeglass prescription of ≥ -8.00 or ≥ +8.00 diopters
• Eyeglass best-corrected visual acuity of 20/40 or worse in either eye
• Visual acuity improvement of 2 lines or more with contact lenses

Measure Anisometropia

For anisometropia, document the prescription difference between the right and left eyes. The difference must be at least 3.00 diopters in any meridian between the two eyes.

• Measure and record the prescription difference between the right and left eyes
• Threshold: ≥ 3.00 diopters in any meridian

Document Aniridia and Irregular Astigmatism

For aniridia and irregular astigmatism, document the specific clinical findings supporting each diagnosis, including iris underdevelopment or absence and the astigmatism measurement with meridian separation.

• Aniridia: underdevelopment or absence of the iris
• Irregular astigmatism: 2.00 diopters of astigmatism in either eye
• Principal meridians separated by less than 90 degrees

Document the Low-Vision Evaluation

A comprehensive low-vision evaluation must document functional difficulties involving daily activities. The evaluation may result in treatment options such as low-vision aids and should assist with identifying other resources for vision and lifestyle rehabilitation.

• Include a history of functional difficulties involving daily activities
• Document possible treatment options, including low-vision aids, when appropriate
• The comprehensive evaluation is supplemental to the eye examination when the examination indicates a need

Diagnosis Must Be Listed

Medically necessary or visually required contact lenses are available only for the diagnoses listed in the policy. These criteria do not imply or guarantee coverage for diagnoses outside the listed criteria.

• Verify that the diagnosis is listed in the policy before submitting the request
• Criteria do not imply or guarantee approval or coverage outside the listed diagnoses

Claims Are Subject to Audit

Submit the appropriate contact lens fitting code and HCPCS Level II codes for prescribed materials according to current coding definitions. All claims for medically necessary services are subject to review and audit.

• Use the appropriate contact lens fitting code under the current AMA CPT definition
• Describe all prescribed materials with the appropriate HCPCS Level II code
• Claims may be reviewed and audited