Gas Permeable Scleral Contact Lens

POLICY NUMBER

L.9.03.403

DESCRIPTION

Gas permeable scleral contact lenses, which are also known as ocular surface prostheses, are formed with an elevated chamber over the cornea and a haptic base over the sclera. Scleral contact lenses are being evaluated in patients with corneal disease, including keratoconus, Stevens-Johnson syndrome, chronic ocular graft-versus-host disease, and in patients with reduced visual acuity after penetrating keratoplasty or other types of eye surgery.

Scleral contact lenses create an elevated chamber over the cornea that can be filled with artificial tears. The base or haptic is fit over the less sensitive sclera. A scleral contact lens has been proposed to provide optical correction, mechanical protection, relief of symptoms, and facilitation of healing for a variety of corneal conditions. Specifically, the scleral contact lens may neutralize corneal surface irregularities and, by covering the corneal surface in a reservoir of oxygenated artificial tears, function as a liquid bandage for corneal surface disease. This may be called prosthetic replacement of the ocular surface ecosystem (PROSE).

The development of materials with high gas permeability and technologic innovations in design and manufacturing has stimulated the use of scleral lenses. The Boston Ocular Surface Prosthesis (Boston Foundation for Sight) is a scleral contact lens that is custom fit using computer-aided design and manufacturing (i.e., computerized lathe). Another design is the Jupiter mini-scleral gas permeable contact lens (Medlens Innovations and Essilor Contact Lens). The Jupiter scleral lens is fit using a diagnostic lens series. The Procornea (Eerbeek) scleral lens was developed in Europe. There are 4 variations of the Procornea: spherical, front-surface toric, back-surface toric, and bitoric. Lenses are cut with submicron lathing from a blank.

The Boston Ocular Surface Prosthesis, which is the prosthetic device used in PROSE, was approved by the U.S. Food and Drug Administration (FDA) in 1994.

Related medical policies are Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy and Implantation of Intrastromal Corneal Ring Segments .

POLICY

Rigid gas permeable scleral lens may be considered medically necessary for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions:

Use of a rigid gas permeable scleral lens for any other condition is considered not medically necessary.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

State Health Plan (State and School Employees): Refer to the Member's Plan for benefits, limitations, and/or exclusions for this procedure.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

11/17/2011: Approved by Medical Policy Advisory Committee. 

12/03/2012: Policy reviewed; no changes.

11/15/2013: Policy reviewed; no changes.

09/26/2014: Policy reviewed; added policy statement that the use of a rigid gas permeable scleral lens for any other condition is considered not medically necessary.

08/28/2015: Medical policy revised to add ICD-10 codes.

05/27/2016: Policy number L.9.03.403 added. Policy Guidelines updated to add medically necessary definition.

05/24/2018: Medical policy links updated in policy description.

03/21/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

04/30/2024: Policy reviewed; no changes.

07/31/2025: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 9.03.25 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

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