BlueCross and BlueShield of Montana Medical Policy/Codes
Therapeutic Lenses, Scleral Shell
Chapter: Vision
Current Effective Date: November 26, 2013
Original Effective Date: November 01, 1996
Publish Date: November 26, 2013
Revised Dates: June 25, 2002; March 1, 2005; November 2011; October 30, 2013
Description

Eyeglasses and lenses may be prescribed for aphakic patients. Aphakia is defined as the absence of the lens of the eye. This absence of the lens may occur congenitally or from trauma, but is more commonly caused by the extraction of a cataract.

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 lenses are sometimes used as bandage lens. Hard contact lenses are sometimes used to treat keratoconus.

Keratoconus is a degenerative non-inflammatory disorder of the eye in which structural changes within the cornea cause it to thin and change to a more conical shape than its normal gradual curve. Keratoconus can cause substantial distortion of vision, with multiple images, streaking and sensitivity to light all often reported by the patient. Keratoconus is the most common dystrophy of the cornea, affecting approximately one person in a thousand, and it seems to occur in all ethnic groups worldwide, although for some groups the prevalence of keratoconus is greater than others. It is typically diagnosed in the patient's adolescent years and attains its most severe state in the twenties and thirties.

Keratoplasty (PKP) (corneal transplantation) is indicated for a number of serious corneal conditions, e.g., scarring, edema, thinning, and distortion. Lamellar keratoplasty is a partial thickness corneal grafting. Penetrating keratoplasty is full thickness corneal grafting.

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.

The sclera is the white part of the eye—a tough covering that, with the cornea, forms the external protective coat of the eye.

A scleral shell covers the cornea and the anterior sclera. 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.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

NOTE: Eyeglasses and contact lenses are generally a vision benefit and are not included as a medical contract benefit. Check the member’s contract carefully for vision benefit. 

Eyeglasses and contact lenses may be considered medically necessary under a member’s medical benefit plan as prosthetics for the following indications:

  1. Eyeglasses, intraocular lenses, or contact lenses as a prosthetic device following cataract surgery when covered by the benefit contract.
  2. Eyeglasses or contact lenses when initially prescribed to correct a vision change that is a direct result of accidental bodily injury.
  3. Contact lenses for the non-surgical correction of keratoconus (and/or other causes of acquired irregular astigmatism which cannot be corrected by glasses).
  4. Contact lenses for corneal scars, or post penetrating keratoplasty (PKP).
  5. Therapeutic soft contact lenses for treatment of acute or chronic conditions of the cornea (e.g., bullous keratopathy, dry eyes, corneal ulcers, corneal erosions, or keratitis).

NOTE:  Bandage lenses may require frequent changes and may be used on a short or long term basis. The procedure includes the fitting of the lens, as well as replacement of the lens.

NOTE:  Sunglasses are considered not medically necessary if provided in addition to regular cataract glasses or lenses. Tint for glasses is considered a convenience item and is not medically necessary.

Contact lenses or combination of contact lenses and eyeglasses are considered not medically necessary for the treatment of pseudophakia.

Contact lenses or glasses for the treatment of refractive errors are not considered a covered benefit, except under the provisions of a vision benefit contract.

Scleral Shell

Scleral shells may be considered medically necessary 

  1. 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; OR
  2. For premature babies and/or children whose eyes did not develop properly or completely, and using a scleral shell will allow the bone structure of the eye socket as well as the eyelid to develop correctly during growth.

Rationale

Scleral shell prosthesis is a type of hard shell contact lens which covers the outer portion of the eye when the eye is non-functional and shrunken by disease. A scleral shell may preclude the need for surgery and a complete prosthetic eye implant (it also serves to support the surrounding tissue of the eyeball). Scleral shell is used in combination with artificial tears in the treatment of "dry eye" (when the lacrimal gland [tear gland]) fails to provide lubrication for the eye, the scleral shell serves to protect against drying and prolongs the life of the artificial tears, a scleral shell may be considered to be an artificial eye).

Therapeutic lenses can stimulate visual and overall development, prevent adverse visual adaptations, reverse adverse visual adaptations, improve visual performance, and reduce visual stress.

Therapeutic contact lenses (TCLs) have proven to be an effective tool in the management of a wide variety of ophthalmic disorders. Conditions recalcitrant to other treatment modalities may heal rapidly with the use of a TCL. 

The term “therapeutic” is derived from the Greek word “therapeuein” meaning to take care of, or to heal. The term “therapeutic” is often used as if it applied to a specific type of contact lens, when in reality, nearly every lens type can be used in a therapeutic capacity.

2012 Update

A search of peer reviewed literature through July 2012 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

95.32, 95.34, 264.6, 370.06, 370.63, 370.8, 371.0, 371.01, 371.02, 371.03, 371.11, 371.12, 371.13, 371.16, 371.20, 371.21, 371.22,  371.23, 371.30, 371.31, 371.41, 371.46, 371.53, 371.60, 371.61, 371.62, 379.31, 379.32, 743.00,  743.35, 743.41, 743.42, 743.9, 871.0, 871.1, 87102, 871.3, 871.5, 871.6, 871.9, 940.2, 940.3, 940.4, 940.5, 996.51

Procedural Codes: 92071, 92072, 92310, 92311, 92312, 92313, 92314, 92315, 92316, 92317, 92352, 92353, 92358, L8610, Q1004, Q1005, S0500, S0512, S0580, S0581, S0590, S0592, V2020, V2025, V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2115, V2118, V2121, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221, V2299, V2300, V2301, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, V2321, V2399, V2410, V2430, V2499, V2500, V2501, V2502, V2503, V2510, V2511, V2512, V2513, V2520, V2521, V2522, V2523, V2530, V2531, V2599, V2627, V2702, V2627, V2782, V2783, V2784, V2786
References
  1. Khan, J.A.  Dermal graft.  Alternative to Gunderson Flap allows fitting a scleral shell over sensitive cornea.  Ophthalmic Plastic and Reconstructive Surgery (1990) 6(4): 260-4.
  2. Lindahl, K.J., DePaolis, M.D., et al.  Applications of hydrophilic disposable contact lenses as therapeutic bandages.  Clao Journal (1991 October) 17(4): 241-3.
  3. Davis, L.J.  Rigid gas permeable extended wear (RGPEW) for the postoperative patient: a review and clinical observations.  Journal of the American Optometric Association (1994 March) 65(3): 179-86.
  4. Cennamo, G., Rosa, N., et al.  Use of a special device for the treatment of over filtration after glaucoma filtering surgery.  Ophthalmologica (1997) 211(2): 61-5.
  5. Jong, K.Y., and Kastl, P.R.  Bausch &Lomb, CW 79 aphakic extended wear contact lens: long-term follow-up.  Clao Journal (1997 January) 23(1): 78-80.
  6. Gupta, S., Arora, R., et al.  An alternative approach to bandage contact lenses Clao Journal (1998 April) 24(2): 118-21.
  7. Arora, R., Gupta, S., et al.  Disposable contact lenses in penetrating keratoplasty.  CLAO Journal (2000 July) 26(3): 127-9.
  8. Tian, X., Iwatsu, M., et al.  Studies on the update and release of fluoroquinolones by disposable contact lenses.  CLAO Journal (2001 October) 27(4): 216-20.
  9. Speeg-Schatz, C., Flament, J., et al.  Congenital cataract extraction with primary aphakia and secondary intraocular lens implantation in the ciliary sulcus.  Journal of Cataract and Refractive Surgery (2005 April) 31(4): 780-6.
  10. Ma’luf, R.N., Awwad, S.T., et al.  Mucous membrane graft versus Gunderson conjunctival flap for fitting a scleral shell over a sensitive cornea.  Ophthalmic Plastic and Reconstructive Surgery (2005 September) 21(5): 356-8.
  11. Moon, J.W., Shin, K.C., et al.  The effect of contact lens wear on the ocular surface changes in keratoconus.  Eye Contact Lens (2006 March) 32(2): 96-101.
  12. Garcia-Lledo, M., Feinbaum, C., et al.  Contact lens fitting in keratoconus.  Comprehensive Ophthalmology Update (2006 March-April) 7{2): 47-52.
  13. Geerards, A.J., Vreugdenhil, W., et al.  Incidence of rigid gas-permeable contact lens wear after keratoplasty for keratoconus.  Eye Contact Lens (2006 July) 32(4): 207-10.
  14. Quah, S.A., Hemmerdinger, C., et al.  Treatment of refractory vernal ulcers with large-diameter bandage contact lenses.  Eye Contact Lens (2006 September) 32(5): 245-7.
  15. Colin, J., and F.J. Malet.  Intacs for the correction of keratoconus: two year follow-up.  Journal of Cataract and Refractive Surgery (2007 January) 33(1): 69-74.
  16. Choi, J., Wee, W.R., et al.  Changes of ocular higher order aberration in on- and off-eye of rigid gas permeable contact lenses.  Optometry and Vision Science (2007 January) 84(1): 42-51.
History
November 2011  Policy reviewed, Removed Congentital from Aphakia policy statement; Added dx code 743.35
February 2012 CPT codes 92071 and 92072 added to policy to replace code 92070
November 2013 Policy formatting and language revised.  Combined "Contacts for Keratoconus and Other Medical Conditions of the Eye" and "Lenses and Frames After Cataract Surgery" policies.  Title changed to "Therapeutic Lenses, Scleral Shell".  Added additional medically necessary indications for eyeglasses and contact lenses.  Added coverage for scleral shells.
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Therapeutic Lenses, Scleral Shell