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    Prior authorization for scleral lenses

    Some plans want to approve scleral lenses before they're ordered. Here is what prior authorization is, how the request usually works, what it does and doesn't promise, and the questions to ask so it doesn't hold up your fitting.

    By the Scleral Lens Team · Last reviewed October 2, 2026 · 4 published sources cited

    The short answer

    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.

    Key points

    • It's a medical necessity decision made before the service, not a payment guarantee.
    • Your fitter's office usually submits it, with records and a letter.
    • Ask your medical and vision plans separately: each may have its own rules.
    • Get the approval number, what it covers, and how long it lasts.
    • A prior authorization denial can be appealed.

    What prior authorization is

    HealthCare.gov defines preauthorization as a decision by your health insurer or plan that a service, treatment plan, prescription drug, or durable medical equipment is medically necessary. It’s also called prior authorization, prior approval, or precertification. Plans may require it before you receive certain services, and it “isn’t a promise” that the plan will cover the cost.[1]

    For scleral lenses, it typically means your fitter sends the plan your diagnosis, test results, and a statement of medical necessity, and the plan agrees in advance that the lenses (and sometimes the fitting) meet its criteria.

    When plans require it

    It depends on the plan. Some medical plans require it for the fitting, the lenses, or both. Many vision plans review medically necessary contact lenses against written criteria; one plan’s published criteria list the qualifying diagnoses and the tests needed to document them.[3]

    You can’t tell from the type of lens alone. Ask.

    How the process usually works

    1. Your fitter examines you and confirms the plan. The office checks your benefits and whether authorization is required.
    2. The office submits the request. It includes your diagnosis, test results such as corneal topography, what’s been tried before, and the services and lenses requested, usually with codes.
    3. The plan reviews it. It may approve, ask for more information, or deny.
    4. You get a decision in writing. For most private health plans, if the plan denies a prior authorization request, it must tell you in writing, and explain why, within 15 days.[2] Vision plans and other plan types may follow different timelines, so ask.
    5. Lenses are ordered. Once approved, keep the authorization number with your records.

    If you have Original Medicare

    Original Medicare doesn’t work the same way. If your provider or supplier thinks Medicare won’t pay for an item or service, they may give you an Advance Beneficiary Notice of Non-coverage (ABN), which lists the items, an estimated cost, and the reason Medicare may not pay. If you choose the option to receive the item and have a claim submitted, you are responsible for payment if Medicare denies it, but you can appeal.[4] Medicare Advantage plans set their own authorization rules.

    If the request is denied

    Read the denial letter for the reason. Common fixable reasons are missing test results, a criterion that wasn’t addressed, or the request going to the wrong plan or benefit. Your fitter can resubmit or appeal. For most private plans, you have 180 days from the denial notice to file an internal appeal, and you can include a letter from your doctor.[2] See the guide to appealing a denied claim.

    What to ask your plan

    1. Does my plan require prior authorization for a scleral lens fitting? For the lenses? For replacement lenses?
    2. Is that under my medical plan, my vision plan, or both?
    3. What documentation do you need? Do you have a form or written criteria?
    4. How long does a decision usually take, and how will I be told?
    5. Once approved, how long is the authorization valid, and does it cover remakes during the fitting?
    6. Does it apply if my fitter is out of network?

    What to ask the practice

    1. Will you check whether authorization is required and submit the request?
    2. Will you wait for approval before ordering lenses?
    3. If approval is denied, what will I owe for the work done so far?
    4. Can I get a copy of the approval or denial and the authorization number?

    Common questions

    Who submits the prior authorization request?

    Usually the practice, because the plan wants clinical records and a doctor's statement. If your fitter is out of network, ask whether they will submit it or whether you need to; some out-of-network plans still require it.

    Can the fitting start before approval comes through?

    Sometimes the exams can go ahead while the lenses wait. Ask the practice what they do, and what you'd owe if approval is denied after work has started.

    My plan approved it. Why did I still get a bill?

    Approval says the service is medically necessary. You may still owe a deductible, copay, or coinsurance, amounts above the plan's allowance, or charges for items the approval didn't include. Compare the bill with your explanation of benefits and ask the plan if something doesn't match.

    Does Original Medicare use prior authorization for contact lenses?

    Original Medicare works differently from private plans. Instead, a provider may give you an Advance Beneficiary Notice if they expect Medicare not to pay. Medicare Advantage plans set their own rules, so ask your plan.

    Keep reading

    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.

    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.

    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.

    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.

    Sources

    1. HealthCare.gov. Glossary: Preauthorization. healthcare.gov
    2. HealthCare.gov. Internal appeals. healthcare.gov
    3. Davis Vision. Medically Necessary Contact Lens Clinical Criteria. Dated July 1, 2026. Published by the Washington State Health Care Authority (SEBB). hca.wa.gov
    4. Medicare.gov. Your protections: Advance Beneficiary Notice of Non-coverage. medicare.gov

    Last updated October 2, 2026. Found an error or a newer study? Let us know and we'll correct the page.