Sclerals and insurance?

[syclone]

Hi

Maybe the ones who have Sclerals could inform me if their insurance covered their lenses? Also, does anyone have a clue where can I find something pretty in-depth and solid package of information about these lenses because my insurance covers only widely know and efficient treatments, so I think I`ll have to get them more information. I hope I`ll find something "official enough" to convince them...

[Silverlady]

This is discouraging...

no answers to this one either.

I really wish there were some place to go for help in justifying to your insurance company why sclerals are necessary. And in finding out how to file the insurance correctly to get even part of the lens covered. I can't see. Oh well, I can see enough to walk thru the house, but I can't see to drive in the daytime and forget night! I haven't driven at night in 4 years except once in an emergency. And I prayed all the way to the hospital there would be no one on the road.

My one attempt at getting Panoptx fitted was a disaster and I had to drive over 100 miles to get them. I only wear them when necessary. Even with them my vision isn't good. I can't read roadsigns, can't see tv, can't sew, can't read books, can't, can't, can't. The list goes on and on. I have highpowered reading glasses that I use to make jewelry and to read my small local newspaper. That's pretty much all of the world I see clearly.

My vision seems to change daily depending on how much moisture my eyes are putting out, so.. glasses that I can see out of one day, I can't the next day. There has to be some place where I can find the information for my eye doctor to file on medical and get my lens covered.

Billy

[Rebecca Petris]

Also, does anyone have a clue where can I find something pretty in-depth and solid package of information about these lenses because my insurance covers only widely know and efficient treatments, so I think I`ll have to get them more information. I hope I'll find something "official enough" to convince them...

I would start with the published medical literature. Here are the abstracts from two publications. I think it costs maybe $25-35 to get reprints of the articles in their entirety.

Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty.

Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease.

(((((Billye)))))
Sending you a PM about the new moisture chamber coming out.

I will see if I can dig up anything about the coding. Can the dr's office help at all? There are several other ODs around the country fitting sclerals for various indications and I would think that at least some of their patients have been able to get some insurance coverage for it...

[kurt]

I posted this on Lasermyeye.org.
I believe that Blue Cross of Massachusetts started covering the cost of the Bostion Foundation for Sight scleral contact lenses, like, a year or two ago. I know someone who had insurance through BC/BS of Virginia, and his BFS lenses were covered (I believe the entire cost). I don't remember if he had to point out to BC/BS of VA that BC/BS of MA was covering the lens.

I know of someone who applied for financial assistance to BFS. And when BFS contacted this individual's insurance company in order to determine how much the ins. company would cover, the insurance company said claim (which contains the insurance codes) would first have to be submitted. They would not say if (or how much) they would cover the lens.

The Needham Sheraton provide a discounted rate for BFS patients (which was $100 a night in 2006), and free transportation to and from BFS is provided by the hotel.

The cost of the BFS lens is $7,800. Janet Cotter, O.D., who was the director of clinical services at BFS for ten years, is now in private practice in Revere MA (about fifteen minutes from the Boston Logan Airport). Her website is Parkway Sclerals. I know someone who was fitted by her and the cost was under $3,000. He had to make four trips to see her. He lived in Maryland.

Gelflex also makes a scleral lens. To find a Gelflex scleral fitter:
Gelflex USA
144 Old Brookfield Road. Danbury, CT 06811
Phone (203) 730-8700
Fax (203) 730-1131
Toll Free 866GELFLEX
Email jhagendorf@gelflex.com

Also, Dr. Gemoules is now fitting scleral lenses. He has an arrangement with a local Comfort Inn that offers $65/night and, I believe, transformation to/from his clinic.

[Rebecca Petris]

For BFS specifically, I understand that at least half of the major insurers offer coverage for BSLs now. But I don't know what indications they offer coverage for. Whether they can make a determination in advance, I don't know. But years ago when I was getting an expensive eye surgery I went through the process of trying to convince my insurer to cover it. In cooperation with my surgeon I put together a report for the insurer and submitted it (before the surgery). To my surprise they agreed to cover the whole thing. It was a lot of work, but it was worth it.

I should think that each practice that fits sclerals would have at least some experience - via hearsay from their own patients who had submitted claims even if the practice had not taken responsibility for filing the claims - as to which insurers have covered sclerals and for what specific indications.

Long-winded way of saying, there may not be any real shortcuts here.

[Rebecca Petris]

Janet Cotter, O.D., who was the director of clinical services at BFS for ten years, is now in private practice in Revere MA (about fifteen minutes from the Boston Logan Airport). Her website is Parkway Sclerals. I know someone who was fitted by her and the cost was under $3,000. He had to make four trips to see her. He lived in Maryland.

This cost is typical of what I have heard of several other fitters around the country. I think that for clarity's sake it would be fair to state that Dr. Cotter's former work at BFS doesn't imply that the 'product' is the same, as BFS lens design and manufacturing process is unique to them, just as each other lens company's are unique to that company.

[kurt]

For FAQs on Janis Cotter's practice, see Parkway Scleral FAQs:

There are two types of gas permeable scleral lenses available today. For the most part the lens materials are very similar. The lens designs however are different.
Fenestrated scleral lenses have actual holes in the lenses to allow tears to move in and out of the lens compartment to prevent lens suction and as an added source of oxygen. This sometimes allows air to get in too which can be a problem. Fenestrated lenses are the easiest for patients to put in but are often the hardest to fit.
Nonfenestrated scleral lenses allow tears to move in and out of the lens compartment by adjusting the fit of the support portion of the lens or by adding channels or tunnels into the lens surface. This makes the lens a little harder to insert but has the advantage of excluding any air bubbles in the lens reservoir.

Both lenses are nonfenestrated lenses. It is the design of the lenses that is different. There will be some patients that are better fit with a lens design from Parkway Sclerals and some patients who will be better fit with Dr. Rosenthal's design. The majority of patients can be fitted successfully with either design.
As a private practice, Parkway Sclerals has a lower overhead and can better control the costs of fitting scleral lenses than larger nonprofit research foundations. Doctor Cotter has made it a priority to ensure scleral lenses are affordable for those who can benefit from their use.

[Rebecca Petris]

And getting back to the original question, maybe she's got those coveted insurance codes.

[Silverlady]

Many thanks to all of you

It gives me a place to start. This is certainly more info than I had to start with. Surely these doctors will share these codes.

Billye

[kurt]

Even if someone doesn't have vision coverage to cover, say, optometrist visits, if the they have major medical coverage, and if the lens is a medical necessity (which is typically the case with scleral lenses), a claim can be submitted to your major medical carrier.

[Silverlady]

good idea Kurt

A medical reason such as Sjogren's Syndrome will qualify you under medical insurance. I've had to use it before.

Billye