Question 1

Does VSP cover scleral lenses for keratoconus?

Accepted Answer

Yes — VSP covers scleral lenses as Visually Necessary Contact Lenses. Since June 2024, VSP requires documentation of a two-line or greater improvement in best-corrected visual acuity compared to glasses. Most keratoconus patients easily meet this threshold. A materials copay applies.

Question 2

Does Medicare cover scleral lenses?

Accepted Answer

Medicare covers the scleral lens fitting and evaluation (CPT 92072), but by law does not cover lens materials. Contact lenses fall under Medicare's statutory refractive lens exclusion. Patients can use HSA funds or financing options such as CareCredit for lens costs.

Question 3

Does Blue Cross cover scleral lenses in California?

Accepted Answer

Yes — Anthem Blue Cross and Blue Shield of California cover scleral lenses as medically necessary for keratoconus (H18.6), keratitis sicca, and aphakia. Prior authorization is typical. We obtain pre-authorization on your behalf before beginning the fitting process.

Question 4

Does UnitedHealthcare cover scleral lenses?

Accepted Answer

Yes — UnitedHealthcare covers scleral lenses through the medical benefit, not the vision rider. Pre-determination of reimbursement is recommended. The claim must go through the medical network provider pathway.

Question 5

Does Aetna cover scleral lenses?

Accepted Answer

Aetna covers the scleral lens fitting and evaluation as medically necessary (CPB 0126). Coverage for lens materials depends on specific plan exclusion language. Prior authorization is required.

Question 6

What diagnosis codes qualify for medically necessary scleral lenses?

Accepted Answer

The primary code is H18.6 (keratoconus). Qualifying diagnoses span seven categories: corneal ectasias (keratoconus, keratoglobus, pellucid and Terrien's marginal degeneration, post-LASIK/post-RK ectasia), corneal stem cell deficiency (Stevens-Johnson syndrome, chemical burns, aniridia Q13.1, ocular cicatricial pemphigoid), neurotrophic corneas (herpes simplex/zoster keratitis, diabetic corneal neuropathy, Riley-Day syndrome), severe dry eye (Sjogren's syndrome, GVHD, radiation-induced, meibomian gland dysfunction), autoimmune corneal disease (rheumatoid arthritis corneal melting, epidermolysis bullosa, ectodermal dysplasia), corneal exposure (lagophthalmos, Bell's palsy), and other conditions (aphakia, post-keratoplasty astigmatism, corneal dystrophies).

Question 7

Are scleral lenses covered for Stevens-Johnson syndrome?

Accepted Answer

Yes. Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are among the strongest indications for scleral lenses. The lenses function as an ocular surface prosthesis, creating a fluid reservoir that protects the damaged corneal surface. All major insurers — Aetna, BCBS, UHC, and Cigna — classify this as medically necessary.

Question 8

Are scleral lenses covered for graft-versus-host disease (GVHD)?

Accepted Answer

Yes. Chronic graft-versus-host disease causes severe dry eye that does not respond to drops alone. Scleral lenses with a saline reservoir provide continuous hydration and are covered as medically necessary when standard dry eye treatments have failed.

Question 9

Are scleral lenses covered for neurotrophic keratitis?

Accepted Answer

Yes. When the cornea loses sensation — from acoustic neuroma surgery, herpes zoster ophthalmicus, trigeminal nerve damage, or diabetic corneal neuropathy — scleral lenses protect the cornea from breakdown. Covered as medically necessary by Aetna (CPB 0126), BCBS, and most commercial plans.

Question 10

What corneal dystrophies qualify for scleral lens coverage?

Accepted Answer

Anterior corneal dystrophies including Meesmann's dystrophy, Cogan's microcystic dystrophy, and Salzmann's nodular degeneration qualify when they cause irregular astigmatism that cannot be corrected with glasses. Corneal ectasias — keratoconus, keratoglobus, pellucid marginal degeneration, and Terrien's marginal degeneration — also qualify.

Question 11

Are scleral lenses covered after corneal transplant?

Accepted Answer

Yes. Post-keratoplasty irregular astigmatism is a standard indication for scleral lenses. The lens corrects the irregular corneal surface while protecting the graft. Most plans cover them when glasses cannot achieve adequate visual acuity.

Question 12

Does insurance cover scleral lenses for corneal exposure (lagophthalmos)?

Accepted Answer

Yes. Both anatomic and paralytic lagophthalmos — including Bell's palsy and CN VII palsy — are covered indications. The scleral lens protects the exposed cornea and maintains a hydrating fluid layer over the ocular surface.

Question 13

Do I need prior authorization for scleral lenses?

Accepted Answer

Most insurance plans require prior authorization for scleral lenses. Our office obtains pre-authorization on the patient's behalf, submitting corneal topography documentation and visual acuity records to demonstrate medical necessity.

Question 14

What if my insurance denies scleral lenses?

Accepted Answer

If your initial claim is denied, we assist with the appeal process by providing corneal topography, best-corrected visual acuity documentation, and a letter of medical necessity. Many denials are overturned on appeal. HSA, FSA, and CareCredit financing are available as fallback options.

Plan	Covers Scleral Lenses?	Key Requirement	Prior Auth
VSP	Yes	≥2-line BCVA improvement vs glasses (since Jun 2024)	No, but documentation required
EyeMed	Yes	Severity criteria + documentation (tightened May 2024)	Varies by employer plan
Anthem BCBS (CA)	Yes	Keratoconus, keratitis sicca, aphakia listed	Typical
Blue Shield CA	Yes	Failed conventional correction	Plan-specific
UnitedHealthcare	Yes	Must go through medical network, not vision rider	Pre-determination recommended
Aetna	Fitting covered; materials plan-dependent	CPB 0126: fitting medically necessary	Yes
Cigna	Case-by-case under medical benefit	Documentation of medical necessity	Yes
Health Net / Medi-Cal	Yes	Prior auth through DHCS Vision Services Branch	Yes (mandatory)
MES (MESVision)	Yes	One pair fully covered with approval	Yes
Medicare	Fitting YES; lenses NO	Statutory refractive lens exclusion	N/A

Scleral Lens Insurance Coverage: Plan-by-Plan Guide (2026)

Coverage by Insurance Plan

HCPCS and CPT Billing Codes

Qualifying Diagnoses for Medical Necessity

Irregular Astigmatism and Corneal Ectasia

Corneal Stem Cell Deficiency

Neurotrophic (Anesthetic) Corneas

Severe Dry Eye

Corneal Disorders with Systemic Autoimmune Disease

Corneal Exposure

Other Qualifying Conditions

Why Insurance Classifies Scleral Lenses as Medically Necessary

We Verify Your Insurance Before Your Visit

How We Handle Insurance for You

Insurance Plans We Accept

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Medical Plans

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