04 Jan Medically Necessary vs Elective Contact Lenses

With good communication between us and your vision insurance carriers, we can often get vision plan benefits to apply to medically necessary contact lenses. Elective contact lenses for cosmetic purposes are often covered as well. It all starts will all of us being on the same page about the expected outcome and necessity of them.

Elective Contact Lenses

When an individual requires vision correction, he or she often misinterprets a prescription as a medical necessity:  “I have poor vision, and my eye doctor wrote the prescription for contact lenses, which improves my vision.  So, my contact lenses are medically necessary.” Unfortunately, this is not quite right.

In most instances, an individual can receive vision correction through eyeglasses, contact lenses, or sometimes laser surgery.  However, eyeglasses are considered the professional standard of care, providing an agreeable and cost-effective treatment.  The other two options are elective and considered cosmetic.  Many vision plans include an elective contact lens benefit in which an individual may choose to correct their vision with contact lenses instead of eyeglasses.

Medically Necessary Contact Lenses

Medically necessary contact lenses are non-elective contact lenses prescribed when certain medical conditions hinder vision correction through regular eyeglasses and contact lenses are the  accepted standard of treatment. With some medical conditions, patients are unable to achieve a specified level of visual acuity or performance through regular eyeglasses. This results in the need for “medically necessary contact lenses.”

Such medical conditions include:

• Aphakia – the removal or absence of the lens of the eye(s) due to surgery, injury, or abnormality.
• Anisometrophia – a refractive condition where the eyes have unequal focus or optical power
• Keratoconus – an eye disease that causes structural damage to the eye’s cornea, changing from the normal, round shape to a bulging, cone shape.

Usually, the medically necessary contact lens benefit is greater than the elective contact lens benefit, and some vision plans will pay a benefit for medically necessary contact lenses even if the plan does not have elective contact lens coverage.