The letter of medical necessity for scleral lenses

What the letter is for

Insurers decide coverage against written criteria. A letter of medical necessity is your fitter’s case that you meet them. It goes with a prior authorization request, a claim, or an appeal.

Plans don’t all use the same name. You may see “statement of medical necessity,” “letter of medical necessity,” or a plan-specific form.

What plans say they need

One vision plan’s published policy (from 2022) is a useful example of what plans look for. It required:^[1]

• a signed statement of medical necessity documenting the specific indication for the patient, accompanied by the supporting medical record
• the relevant medical history, physical examination, and results of diagnostic tests
• the prescription for the lenses

It also said stamped signatures were not acceptable and that every page of the record had to be legible and identify the patient.^[1]

Plans also tie their criteria to specific tests. For keratoconus, for example, a current vision plan list asks for topography, OCT, or corneal mapping, or keratometry.^[2] A medical policy lists corneal topography as part of the covered evaluation for keratoconus and other irregular corneas.^[3]

A sample outline

This is a general structure, not a template from any plan. Your fitter’s office will adapt it to your plan’s criteria and their own clinical findings.

1. Patient and plan details. Your name, date of birth, member ID, group number, and the claim or authorization number if there is one.
2. Diagnosis. The condition or conditions, in each eye, with the diagnosis codes the practice uses.
3. Clinical findings. The measurements that support the diagnosis: for example, topography or tomography results for an irregular cornea, or findings that document ocular surface disease. Attach the reports.
4. How the condition affects vision or the eye. Best corrected vision with glasses compared with the vision expected or achieved with a scleral lens, and any symptoms such as pain or light sensitivity.
5. What has already been tried. Glasses, soft lenses, corneal gas permeable lenses, hybrid lenses, drops or other treatments, with dates where possible, and why each wasn’t enough.
6. Why a scleral lens. The specific reason this lens is needed for this eye: for example, that it vaults an irregular cornea or keeps the surface covered in fluid.
7. What’s being requested. The services and lenses, with the codes the practice will bill, for each eye.
8. Criteria addressed. A sentence that points to each item on the plan’s own criteria and says where in the record it is documented.
9. Signature. The treating doctor’s signature, credentials, contact details, and date.

How you can help

• Get the criteria. Call your plan and ask for its written medical necessity criteria for contact lenses. Pass them to the office.
• Gather old records. Notes from past eye doctors about lenses you’ve tried, surgery reports, and earlier topography help show history.
• Write down what you’ve tried. A simple list with approximate dates and what went wrong saves the office time.
• Ask for a copy. Keep the letter and the attachments. You may need them for replacement lenses, a new plan, or an appeal.

If the plan says no

A denial letter should tell you why. That reason tells your fitter what the next letter needs to address. For most private plans, you can file an internal appeal and include a letter from your doctor with any additional information you want considered.^[4] See the guide to appealing a denied claim.

What to ask your fitter’s office

1. Do you write medical necessity letters for this plan? Is there a fee?
2. Which tests in my record support the criteria?
3. Will you send the letter with the prior authorization request, or with the claim?
4. Can I have a copy of what you send?