THERAPEUTIC LENSES/SCLERAL SHELL DME104.003 _____________________________________________________________________ COVERAGE: This policy addresses conditions where eyeglasses or lenses (including contact lens) may be considered medically necessary for the treatment of disease, injury or congenital malformation. Note: A contract exclusion will always take precedence over this policy. Eyeglasses and Lenses for an Aphakic Patient Eyeglasses and lenses are medically necessary if the patient has a history of having had cataract surgery. These glasses are sometimes called cataract glasses. The following lenses or combinations of eye glasses and lenses are medically necessary for a diagnosis of aphakia only (not pseudophakia): 1.Bifocals; 2.Glasses plus reading glasses; 3.Contacts plus reading glasses plus cataract glasses. Note: Sunglasses are not medically necessary if they are provided in addition to regular (untinted) cataract glasses. Hard Contact Lenses Hard contact lenses are medically necessary for the non-surgical correction of a corneal defect such as keratoconus (and/or other causes of Acquired Irregular Astigmatism which cannot be corrected by glasses), corneal scars, or post penetrating Keratoplasty (PKP). Refer to the description section of this policy for a definition of keratoconus. Soft Contact Lenses Soft contact lenses are medically necessary for a diagnosis of aphakia or when used as a corneal bandage. Coverage includes one initial lens, one replacement lens for each aphakic eye in the first year and then one replacement lens per each aphakic eye per year thereafter. Bandage Lenses A bandage lens is medically necessary for treatment of a diseased or injured eye and to correct an irregular cornea. The bandage lens may require frequent changes and may be used on a short or long-term basis. This procedure includes the fitting of the lens, as well as replacement of the lens.
Scleral Shell Scleral shells are medically necessary when used as an artificial eye or for corneal coverage when the eye has been rendered sightless, shrunken and/or deformed. This may include coverage for phthisis and disfiguring cornea opacity in people who are not candidates for corneal transplantation. Scleral lenses are also medically necessary for premature babies and/or children whose eyes did not develop properly or completely. Using a scleral shell will allow the bone structure of the eye socket as well as the eyelid to develop correctly during growth. _____________________________________________________________________ DESCRIPTION: Eyeglasses and Lenses for an Aphakic Patient Eyeglasses and lenses may be prescribed for aphakic patients. An aphakic patient is one with absence of the lens of the eye. Absence of the lens may occur congenitally or from trauma, but is more commonly caused by extraction of a cataract. Hard or Soft Contact Lenses A contact lens is a small curved glass or plastic lens shaped to fit the patient's eye and to correct refraction. Contact lenses float on the precorneal tear film and must be inserted, removed, and stored as directed to avoid damage or infection to the eyes. Contact lens are sometimes used as bandage lens. Hard contact lenses are sometimes used to treat keratoconus that is a non-inflammatory, usually bilateral protrusion of the cornea, the apex being displaced downward and nasally. It occurs most frequently in females about puberty. The cause is unknown, but hereditary factors may play a role. Bandage Lenses A bandage lens is a disposable soft, extended wear soft, or hard contact lens fitted by the physician for the treatment of a diseased or injured eye. A bandage lens may also be used to correct an irregular cornea. The bandage lens may be applied over the surface of the eye to promote corneal epithelial wound healing following corneal surgery and/or non- healing corneal injuries. The product is a clear, pliable, absorbable, thin film and provides relief of discomfort and may deliver drugs to the healing cornea postsurgically. Scleral Shell A scleral shell covers the cornea and the anteriorsclera. The scleral shell is used to cover a blind, unsightly eye that has not otherwise deteriorated to a condition that requires enucleation. Phthisis bulbi (shrinking of the eye) is a common reason for the fitting of a scleral shell. _____________________________________________________________________ RATIONALE: See Coverage section. _____________________________________________________________________
DISCLAIMER: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, takes precedence over Medical Policy and must be considered first in determining coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Any benefits are subject to the payment of premiums for the date on which services are rendered. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. HMO Blue Texas physicians who are contracted/affiliated with a capitated IPA/medical group must contact the IPA/medical group for information regarding HMO claims/reimbursement information and other general polices and procedures. ______________________________________________________________________ Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO Blue Texas * Independent Licensees of the Blue Cross and Blue Shield Association ______________________________________________________________________ Posted Jan. 7, 2003