Insurance and cost
Insurance and cost
How scleral lenses are billed and covered: medical versus vision plans, medical necessity, prior authorization, out-of-network claims, Medicare and Medicaid, and paying with an HSA or FSA. Rules change, so every page shows when it was last reviewed.
How much do scleral lenses cost? It varies widely, and very little reliable price data is published. The bill has two main parts: the professional fitting (exams, measurements, follow-up visits) and the lenses themselves, and both grow with the number of visits and remakes your eyes need. One published US estimate put the lenses at several hundred dollars per eye and the initial fitting at several hundred more, at a single academic health system. Ask the practice for a written estimate that spells out what is and isn't included. Updated October 2, 2026 Medical insurance or vision insurance: which one pays for scleral lenses? Often it's split. Your medical plan may cover the exams and the fitting for an eye disease like keratoconus, while the lenses themselves are excluded and left to a vision plan, if you have one. Many vision plans have a separate, richer benefit for medically necessary contact lenses. Severe ocular surface disease is sometimes treated differently. Call both plans and ask the questions below. Updated October 2, 2026 What counts as medically necessary contact lenses? It means lenses needed to treat or see with a qualifying eye condition, where glasses don't do the job. Plans that publish criteria commonly list keratoconus and other irregular corneas, very high prescriptions, a large difference between the eyes, missing natural lens or iris, and severe ocular surface disease. Each plan sets its own conditions, measurements, and paperwork, and meeting the criteria doesn't guarantee approval. Ask your plan for its written criteria. Updated October 2, 2026 The letter of medical necessity for scleral lenses It's a signed letter from your eye doctor explaining your diagnosis, the test results that support it, what you've already tried, and why scleral lenses are needed. Plans that publish their requirements ask for the specific indication, supporting history, exam and test results, and the lens prescription. Your fitter writes and signs it; you can help by getting your plan's written criteria and your old records to the office. Updated October 2, 2026 Prior authorization for scleral lenses Prior authorization is your plan agreeing in advance that a service or item is medically necessary. Many plans require it for medically necessary contact lenses; your fitter's office usually submits it with your records. Approval isn't a promise to pay: the claim can still be limited by your benefits, deductible, and network. Ask both your plan and the practice whether it's needed before any lenses are ordered. Updated October 2, 2026 Scleral lens billing codes, explained Scleral lens claims usually have two kinds of code: a HCPCS code for the lens itself (V2531 is 'contact lens, scleral, gas permeable, per lens') and a CPT code for the fitting, such as 92071 for ocular surface disease or 92072 for the initial keratoconus fitting. A diagnosis code explains why. The practice picks the codes; your plan decides what it pays for them. Knowing the codes helps you ask your plan precise questions. Updated October 2, 2026 Does Medicare cover scleral lenses? Original Medicare doesn't usually cover contact lenses, including scleral lenses used to correct vision for conditions like keratoconus. The exceptions are narrow: lenses after cataract surgery or for an eye without its natural lens, and, in rare cases, a scleral lens used as a prosthetic to protect an eye with severe dry eye. Medicare Advantage plans may add vision benefits. Ask your plan and confirm the practice is a Medicare-enrolled supplier. Updated October 2, 2026 Does Medicaid cover scleral lenses? It varies by state. For adults, eyeglasses and other aids to vision are an optional Medicaid benefit, so each state decides whether to cover them and on what terms. For people under 21, the EPSDT benefit requires states to cover medically necessary treatment for vision conditions, even services the state plan doesn't list. Ask your state Medicaid agency or Medicaid health plan, and ask fitters whether they accept Medicaid. Updated October 2, 2026 Out-of-network claims and superbills for scleral lenses A superbill is an itemized statement from the practice with the codes, diagnoses, dates, and provider details your plan needs to process a claim. If your plan has out-of-network benefits, you submit it and the plan reimburses part of the cost based on its own allowed amount, after any deductible and coinsurance. Call your plan first to find out whether you have out-of-network benefits and how much they pay for the codes on your estimate. Updated October 2, 2026 Paying for scleral lenses with an HSA or FSA, and other options Usually yes. IRS Publication 502 says you can include contact lenses needed for medical reasons as a medical expense, along with the supplies needed to use them, such as saline. That generally makes them eligible for HSA and FSA funds. Keep itemized receipts, check your account administrator's documentation rules, and be careful with deferred-interest medical credit cards. Updated October 2, 2026 How to appeal a denied scleral lens claim Start by finding out exactly why the claim or prior authorization was denied. For most private health plans you can then file an internal appeal within 180 days of the denial notice, with a letter from your fitter and the records that answer the reason given. If the plan still says no, you can usually ask for an independent external review. Medicare and some other plan types have their own processes, so check your denial letter. Updated October 2, 2026 Does Aetna cover scleral lenses? Partly. Aetna's medical policy (Clinical Policy Bulletin 0126) considers scleral lenses medically necessary when they are used as a moist corneal bandage for severe ocular surface disease, even under plans that otherwise exclude contact lenses. For keratoconus and other irregular corneas, it covers the evaluation and fitting, but under medical plans that exclude contact lenses the lenses themselves are left to your vision plan, if you have one. Your own plan documents decide, so check them and ask your fitter about prior authorization. Updated October 2, 2026 Does Cigna cover scleral lenses? Sometimes, through a Cigna Vision plan. Cigna Vision schedules of coverage say therapeutic contact lenses are covered when vision can't be corrected to 20/70 in the better eye with glasses and contact lenses would reach that level, and in certain cases of keratoconus, anisometropia, or aphakia, as documented by your eye care professional. The therapeutic benefit can still have an allowance or limits. Whether a Cigna medical plan pays for any part depends on your plan documents, so ask Cigna and your fitter. Updated October 2, 2026 Does UnitedHealthcare cover scleral lenses? Possibly, under your medical plan. UnitedHealthcare's commercial policy on medical equipment says contact lenses used to treat an injury or disease, giving keratoconus and severe dry eye as examples, may be covered as a therapeutic service and are not subject to a plan's contact lens exclusion. 'May be covered' isn't a guarantee: your plan document decides, and some state versions differ. Ask UnitedHealthcare and your fitter's office about prior authorization before lenses are ordered. Updated October 2, 2026 Does Blue Cross Blue Shield cover scleral lenses? It depends on which Blue plan you have. Capital Blue Cross and Arkansas Blue Cross and Blue Shield both publish policies that consider gas permeable scleral lenses medically necessary for keratoconus and other corneal conditions, and for ocular surface disease, in people who haven't done well with medications or standard glasses or contact lenses. Blue Cross Blue Shield of Michigan's policy covers them as a liquid bandage for persistent corneal defects that haven't healed with other treatment. Find your own plan's policy and ask your fitter about prior authorization. Updated October 2, 2026 Does TRICARE cover scleral lenses? For certain conditions, yes. TRICARE's lens policy, as published by the West Region contractor, covers an initial set of corneal or scleral lenses for keratoconus, scleral lenses to retain moisture when normal tearing is absent or inadequate, and corneal or scleral lenses to reduce a corneal irregularity other than astigmatism. Benefits are limited to one set of lenses for the qualifying condition, with replacements only after a prescription change still related to it. Lost or worn-out lenses with an unchanged prescription aren't covered. Updated October 2, 2026 Does the VA cover scleral lenses? For eligible veterans with a qualifying eye condition, often yes. VA provides eyeglasses and contact lenses only to veterans who are receiving VA care and fall into an eligible group under federal regulation, such as those with a compensable service-connected disability. VHA Directive 1034 then lists conditions for contact lenses, including keratoconus, significant corneal pathology, corneal transplant, irregular astigmatism, and specialty lenses for conditions like severe dry eye. A VA eye care provider decides. Ask your VA eye clinic or prosthetics representative. Updated October 2, 2026 Does Kaiser Permanente cover scleral lenses? It depends on your Kaiser region and plan. The Kaiser documents we read describe benefits for 'medically necessary' or 'special' contact lenses rather than scleral lenses by name. One 2026 Southern California Medicare plan covers, for some members, contact lenses that give a significant improvement in vision not obtainable with glasses; a 2026 Northwest vision benefit waives the fitting fee for medically necessary lenses. Kaiser plans generally cover care from Kaiser's own network, so ask your plan and your Kaiser eye care team. Updated October 2, 2026