Scleral lenses covered by medical insurance?

[dswaddling]

What has been the experience of scleral lens wearers regarding coverage by medical insurance?

While I do understand that insurance contracts vary from company-to-company and even individual-to-individual, I am beginning to find that, since scleral lenses are not explicity referenced in most insurance contracts, the insurance companies often process such claims inconsistently and, therefore, unfairly.

I would like to share information about this with other wearers of scleral lenses, in case we can help one another to deal with the various insurance companies: I was first fitted with scleral lenses (for keratoconus) this past July here in Columbus, OH and United Health Care has denied my claim and two follow-up requests for "review." UHC only refers to the clause in my contract which excludes "the costs and expenses in connection with the fitting of eyeglasses, or contact lenses and/or the supply of eyewear" - even though we know that scleral lenses are none of those things.

One of the oddities is that my claim totals "only" $1600 (while the Boston Foundation for Sight's price is $7.600). Apparently, my next step is to "file a civil action," so I am currently investigating how to go about doing that without spending a fortune on lawyers.

Does anyone else have experience in this area that might be helpful to me and others? Thank you!

[mylittlem]

I am currently waiting for Boston Foundation for Sight to obtain a claim precertification from my insurance company. I do not yet know whether CIGNA will accept this. It could be several weeks still before I know. I shall contact you at that time.

[Rebecca Petris]

I don't know too much about it other than that it is an uphill battle. Two thoughts though - 1) Indication for the lenses probably has a lot to do with how they view it. For example, for many people sclerals are an alternative to a corneal transplant. While not all insurers are on board yet, for those that are, it's kind of a no-brainer, because it's lower cost and lower risk for repeat (increased cost) than transplant. Dry eye pain on the other hand - especially if the doctor is not seeing horrendous damage to the surface of the cornea - is a different matter in terms of alternative treatments that they will be thinking of. 2) The BSL, or more properly BOSP (boston ocular surface prosthetic) is FDA approved for treatment of some corneal diseases so I'm guessing that it may be less of a battle with insurers.

If anybody has info to the contrary feel free to set me straight - I don't know too much about this part of it.

[gz9gjg]

Whether your medical or vision insurance covers sclerals or other custom RGPs will vary state to state, as well. Talk to your OD, he should be able to advise you.

I was told in Michigan in 2002 that declaring RGPs "Medically necessary" was a big deal, don't do it, so I used my Flexible Spending account to pay for the lenses instead.

In Arizona in 2008, my OD told me the lenses would be "medically necessary" and would be covered.