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Medical Policy

Policy Num:       09.003.007
Policy Name:     CONTACT LENSES FOR THE PEDIATRIC POPULATION 
Policy ID:          [09.003.007][Ar L M+ P+][0.00.00]

Last Review:       November 10, 2021
Next Review:      N/A
Issue:                   November, 2021

Archived

Related Policies: N/A

CONTACT LENSES FOR THE PEDIATRIC POPULATION 

Summary

It is estimated that 40.9 million people over the age of 18 in the United States (one in six adults) wear contact lenses, 93 percent wear soft lenses and the rest have gas-permeable lenses.

Contact lenses can be classified by their composition material, time of use, total time of use, permeability, water content, and type of correction. With many types of new lenses available, there are alternatives to help most patients achieve the use of comfortable lenses with clear vision. New types of contact lenses are being introduced continuously with the intention of reducing the risks of infection, inflammation and trauma of the conjunctiva and maximize vision correction and comfort of use

Soft lenses are made of different plastic polymers that absorb water (hydrophilic). These materials differ in terms of oxygen permeability (expressed in Dk units, where D is diffusion and k for solubility), water content (which varies between 20 and 70 percent water by weight), quality of the surface (wettability), ultraviolet absorption, and structural consistency (rigidity or modulus). The Food and Drug Administration of the United States (FDA) has developed a classification system for soft lenses.

The maintenance of a smooth and transparent refraction anterior surface is fundamental for good vision. A complex interaction between the cornea and the conjunctival epithelium, the tear film, and the overlapping eyelids offers protection against infection and scarring. Noninfectious complications are minimized with a contact lens with an adjustment that is both based on the pre-corneal tear film and moves just enough to allow good fluid and gas exchange, thereby functioning as a de facto extension of the ocular surface.

Objective

N/A

Policy Statements

Contact lenses are considered for payment for any of the following indications:

A. Congenital aphakia

B. Acquired aphakia after cataract surgery (adult or pediatric);

C. Irregular corneas / corneal scarring when vision cannot be corrected with glasses (for example, keratoconus, after corneal graft surgery, after corneal infection);

D. As a corneal dressing to promote wound healing (eg, corneal ulcer / erosion, keratitis);

E. Refractive errors that cannot be corrected at a sharpness level of 20/40 with glasses.

F. Amblyopia when cannot be corrected otherwise.

Contact lenses are not considered for payment for the following conditions:        

A. Albinism - as an alternative to polarized glasses to reduce sensitivity to light or severe photophobia;

B. Amblyopia- as an alternative to eye patches therapy / traditional pathing of the eye / occlusion or

C. Prior authorization in the correction of refractive errors instead of glasses, except as indicated above.

Policy Guidelines

Preauthorization is required for the entire contact lens service.

Contact lenses used in the treatment of an eye medical condition covered by the benefit of eye care and low vision services for Medicaid, Family Health Plus and Child Health Plus members.

   a. Contact lenses for Medicaid members are eligible for coverage once every 24 months, unless there has been a change in vision that requires a change in prescription or the lenses have been lost or damaged.

   b. Contact lenses for Family Health Plus members are eligible for coverage once every 24 months.

   c. Contact Lenses for Child Heath Plus members are eligible for coverage once every 12 months

Multiple contact lens changes may be necessary in pediatric patients with aphakia whether acquired or congenital.

Contact lens application must include all the following characteristics:

   a. documentation of medical necessity

   b. better corrected vision with and without the lenses

   c. better corrected vision with and without contact lenses

   d. date of the last complete examination of the eyes

   e. refractive error.

Benefit Application

BlueCard/National Account Issues

N/A

Background

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Regulatory Status

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Rationale

Population Reference No. 1-6 Policy Statement

 For individuals with:

1) congenital aphakia,

2) acquired aphakia after cataract surgery (adult or pediatric),

3) irregular corneas or corneal scarring when vision cannot be corrected with glasses,

4) corneal ulcer or erosion or keratitis,

5) refractive errors that cannot be corrected at a sharpness level of 20/40 with glasses,

6) amblyopia when cannot be corrected otherwise treated with Rx contact lenses.

Relevant outcomes include better corrected vision, promote wound healing and correct refractive errors that cannot be corrected otherwise. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 7-10  Policy Statement

For individuals with:

7) albinism (as an alternative to polarized glasses to reduce sensitivity to ligh)t

8) albinism (with severe photophobia),

9) amblyopia (as an alternative to eye patches therapy / traditional pathing of the eye / occlusion),

10) correction of refractive errors instead of glasses, except as indicated treated with Rx contact lense. 

Evidence suggest no additional medical benefit of using this technology when compared to other therapies available.

Supplemental Information

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Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.         Cope JR, Collier SA, Rao MM, et al. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections--United States, 2014. MMWR Morb Mortal Wkly Rep 2015; 64:865.

2.         Dart JK, Radford CF, Minassian D, et al. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology 2008; 115:1647

Codes

Appplicable Modifiers

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Policy History